Lung Cancer: Fellow Case Report Slide: Lung Cancer |

Restrictive EGFR Mutation FREE TO VIEW

Lina Miyakawa, MD; Michael Bergman, MD; Alfred Astua, MD
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Mount Sinai Beth Israel, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):685A. doi:10.1016/j.chest.2016.08.780
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SESSION TITLE: Fellow Case Report Slide: Lung Cancer

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 23, 2016 at 03:15 PM - 04:15 PM

INTRODUCTION: Lung adenocarcinoma is the most common form of lung cancer and typically presents as a dominant mass. Here we present a case of adenocarcinoma presenting as nodular pleural thickening mimicking appearance of mesothelioma.

CASE PRESENTATION: A 66-year-old Chinese non-smoking woman presented with progressive chest pain for 4 months. She had a 15-pound weight loss and was referred for inpatient hypercalcemia evaluation. Her chest X-Ray and subsequent CT showed extensive circumferential pleural thickening with small pockets of loculated pleural effusion and ipsilateral mediastinal and hilar lymph nodes; there was no lung mass identified. Incidentally noted were lytic lesions in her spine and left trochanter. Given the cluster of radiographic findings, a closed pleural biopsy using an Abrams’ needle was performed. Molecular interrogation demonstrated cells to be malignant and positive for adenocarcinoma markers (Napsin A+, TTF-1+); mesothelial and squamous markers were negative. This confirmed the diagnosis of primary lung adenocarcinoma. Genetic analysis later demonstrated a mutation in EGFR. PFT showed restriction with reduced FVC (1.53L, 49% predicted), FEV1 (1.19L, 50% predicted) and TLC (3.25L, 64% predicted). The DLCO was 48% predicted. The patient was started on erlotinib as definitive treatment with palliative radiotherapy to her spine and leg.

DISCUSSION: Adenocarcinoma typically presents as a dominant lung mass. In this case there was no dominant lung mass and her presentation was that of extensive pleural nodular metastases. While bony metastases are uncommon in mesothelioma, her presentation of unilateral nodular lung encasement is far more commonly seen in mesothelioma than adenocarcinoma. Closed pleural biopsy has a sensitivity of 20-70% for mesothelioma and 46-72% for malignancy in general. To our knowledge this is the first documented case of lung adenocarcinoma with an EGFR mutation presenting in this fashion. It is thought that EGFR mutations may facilitate migration of cancer cells to the pleura, mediating metastatic pleural disease.

CONCLUSIONS: Presented here is the first case of EGFR-mutated lung adenocarcinoma presenting in this fashion; disguised in appearance like mesothelioma. With evolving treatment modalities, it is imperative to obtain adequate tissue to aid in identification of driving mutations, thereby allowing initiation of molecular-targeted therapy.

Reference #1: Agalioti T et al. Pleural involvement in lung cancer. Journal of Thoracic Disease. 2015;7(6):1021-1030.

DISCLOSURE: The following authors have nothing to disclose: Lina Miyakawa, Michael Bergman, Alfred Astua

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