A 68-year-old never-smoking female was referred to our outpatient clinic due to the stage IV lung adenocarcinoma, with involvement of the right supraclavicular lymph nodes and pelvic bones. Microscopic diagnosis was obtained via bronchoscopic biopsy and further confirmed by histologic examination of the tissue material form core needle biopsy of the supraclavicular node. The medical history included hypertension, ventricular extrasystoles, secondary hypothyroidism (after partial thyreoidectomy due to thyroid adenoma), degenerative spine disease and hypercholesterolemia. Cisplatin and pemetrexed were used as the 1st line treatment (from December 2010 to March 2011). Due to progression of the lesion in the right lung, the patient received four cycles of docetaxel (from July 2012 to September 2012) and, subsequently, the palliative radiation to the chest in February 2013.\nIn July 2013, the patient was diagnosed with liver metastases. The liver lesion biopsy revealed activating EGFR mutation (exon 19 deletion), and the patient was enrolled in the clinical trial OAM4971G, comparing combination of erlotinib and onartuzumab (monoclonal antibody blocking MET protein signalling) with erlotinib treatment only. During the study the patient developed facial rush (grade 1), recognized as associated with erlotinib treatment. In the chest and abdomen CT (September 2013 and November 2013) tumour partial regression was reported. There were no clinically significant abnormalities in laboratory testing.\nIn March 2014 the patient was informed about negative outcome of the clinical trial. Unblinding revealed that the patient was treated in placebo/erlotinib arm, and, therefore continuation of erlotinib 150 mg QD was offered. The patient did not report any further toxicity until April 2015, when G2 paronychia appeared. The skin changes were located around nail folds, mostly of left hand fingers, and required the use of amoxicillin with clavulanic acid.\nIn July 2015, after 24 months of erlotinib treatment, the progression of liver metastases was diagnosed. The patient was proposed 3rd line chemotherapy, i.e. paclitaxel 80 mg/m2 weekly over 3 week-period and 1 week-break thereafter. The treatment resulted in partial response that was maintained until April 2016. Because of availability of osimertinib within extended access programme, liver metastasis biopsy was performed, resulting in confirmation of T790M resistance mutation by Cobas test. In the abdomen CT (December 2016), further progression of liver metastatic lesions was confirmed, with lesions’ dimensions of 60 x 67 mm and 24 x 36 mm, respectively.\nIn December 2016 the patient began treatment with osimertinib 80 mg QD. In the first follow-up abdomen CT after 8 weeks significant regression of liver metastasis was seen, with reduction of the sum of lesion dimensions by 48%. Currently, after 8 months of treatment the patient is not reporting any side effects. On the last imaging (July 2017) almost complete remission of the liver lesions and full control of the other foci was confirmed, after more than 6 years from the initial diagnosis of the metastatic lung cancer.
The patient was a 68-year-old woman with a medical history of postoperative treatment of NSCLC with bone metastasis 1 year 8 mo before presentation.\nA review of the patient’s medical history revealed nothing significant other than lung cancer and hypertension.\nA review of the patient’s medical history revealed nothing significant other than lung cancer and hypertension.\nThe patient had no significant personal or family history.\nThe patient presented with multiple erythematous papules mainly on the face and thigh on day 74. Seventy-eight days later, the patient developed several oral blisters and scattered erythema papules that rapidly developed into mucosal erosion and systemic epidermal abscission including the skin on the face and back (Figure ). The large area of exfoliation involved 30% of the body surface area. Nikolsky’s sign was positive. Despite the severity of the disease, the patient’s general condition is acceptable.\nRoutine laboratory examination revealed normal alanine aminotransferase (ALT 22 U/L, normal limits 13-69 U/L). Laboratory markers of systemic involvement indicated anemia, leucopenia, hypoalbuminemia, and hyponatremia. More importantly, there was no short-term drug or diet exposure before the outbreak. In addition, the interval between the first administration of AZD-9291 and the onset of disease was consistent with hypersensitivity latency. Bacterial cultures of blood, urine, and blisters revealed no evidence of bacterial infection. A drug lymphocyte-stimulation test was positive for AZD-9291, with a stimulation index of 2.6. As the above information was indicative enough, and the patient refused to have a pathological examination, biopsy was not performed.\nChest computed tomography (CT) showed pulmonary lesions in posterior segment of right upper lobe, and peripheral lung cancer with multiple pulmonary metastases. Multiple metastases of the thoracic vertebrae, sternum, and ribs were considered (Figure and ), which were similar to previous CT images (Figure and ). Follow-up was recommended.