PMC5087704_01
Management of primary lung cancer and brain metastasis during icotinib treatment. Chest computed tomography (CT) on admission (July 2014) (A) showing a 3.7x2.8 cm irregularly shaped lesion in the left lower lobe (LLL); the repeated CT one month after icotinib treatment (B) showing a clear reduction in size of the lesion in the LLL; chest CT revealing dramatic shrinkage of LLL mass after one-year maintenance icotinib treatment (C); enhanced brain magnetic resonance imaging (MRI) scan on admission (July 2014) revealing brain metastasis to the right parietal lobe (D); brain MRI obtained in July 2015 showing the intracranial lesion vanished following maintenance icotinib treatment (E).
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The chest computed tomographic scan revealed a 3.7x2.8 cm mass in the left lower lung (LLL) (Figure 1). Subsequent brain magnetic resonance imaging (MRI) indicated BM (Figure 1). A repeated computed tomography (CT) after one month of therapy disclosed that the left lung mass had partially resolved (Figure 1). In July 2015, a follow-up thoracic CT performed after one year of icotinib therapy revealed dramatic shrinkage of the LLL lesion (Figure 1).
Histology of the primary lung cancer. The hematoxylin and eosin staining revealed that the left lower lobe lesion was a moderately differentiated adenocarcinoma (magnification x100).
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A bronchoscopic biopsy was performed, and histopathologic examination confirmed NSCLC with a moderately differentiated tumor histology favoring adenocarcinoma (Figure 2).
Direct Sanger sequencing and fluorescence in situ hybridization (FISH) analysis of the biopsied lung lesion. A mutant form of EGFR L858R in exon 21 (A) was identified in the left lower lobe (LLL) lesion. Anaplastic lymphoma kinase (ALK) rearrangement was detected by FISH analysis using break-apart probes. Samples are considered to be FISH positive if split ALK 5' and 3' probe signals or isolated 3' signals are detected in at least 15% of counted tumor cells. Approximately 22% of lung adenocarcinoma cells indicate ALK rearrangement, as demonstrated by split red/green signals (B).. Abbreviation: EGFR, epidermal growth factor receptor.
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EGFR mutation and ALK translocation status were identified by direct Sanger sequencing, real-time polymerase chain reaction, and fluorescence in situ hybridization (FISH) analysis, and both were found to be positive (EGFR exon 21 L858R and ALK FISH positive 22% of the cells) (Figure 3A and B).