Lung cancer is the leading cause of cancer death in the world, with non-small cell lung cancer (NSCLC) a significant component of those deaths.1,2 Treatments for advanced-stage NSCLC, however, are limited. Erlotinib, a small-molecule tyrosine kinase inhibitor of epidermal growth factor receptor (EGFR), has aided in advancing NSCLC therapy. Erlotinib has been shown to increase survival by 2 months compared with placebo in a phase 3, randomized controlled trial when used as second- or third-line therapy.3 The authors present a case of a man surviving almost 8 years with late-stage NSCLC on treatment with erlotinib at the VA West Los Angeles Medical Center (WLAMC).
Case Report
Mr. J is a 59-year-old man with a medical history of hepatitis C. He smoked 2 packs of cigarettes a day for 25 years and quit in 2003. He also had a known history of IV drug use. He was unaware of his family history because he was adopted, but his twin sister, who has no known medical problems, is also a smoker. In 2005, when Mr. J was evaluated for treatment options of long-standing hepatitis C with liver ultrasound, a large, irregular right adrenal mass was found, measuring 6.4 x 3.5 cm. A subsequent positron emission tomography (PET) scan identified a lung nodule measuring 3.8 x 3.6 x 3.3 cm. A biopsy guided by computed tomography (CT) showed NSCLC. Subsequently, metastases to the liver and adrenal glands were noted, and Mr. J was started on chemotherapy. He received 4 cycles of carboplatin 725 mg and gemcitabine 2,000 mg as well as a thoracotomy and left upper lung wedge resection in December 2005. His pain was controlled with slow-release morphine 15 mg 2 times per day and oxycodone 5 mg and acetaminophen 325 mg 4 times per day as needed for breakthrough pain.
In 2006, after 4 cycles of chemotherapy, the size of the adrenal mass and the lung mass had decreased; however, he developed new abdominal pain. A CT scan showed new intrahepatic and extrahepatic biliary dilatation and worsening pancreatic function. He could not tolerate the recommended endoscopic ultrasound and left WLAMC, later presenting to an outside hospital for his abdominal pain.
At the outside hospital, 2 masses that were surgically removed from the head of the pancreas were confirmed to be EGFR-positive NSCLC, and he was given 4 cycles of cisplatin and irinotecan at unknown doses. The only adverse effects (AEs) Mr. J reported during this period were nausea and vomiting immediately after chemotherapy. He failed to respond to this treatment and was started on bevacizumab, also at an unknown dose. The patient again did not respond and was transitioned to erlotinib 150 mg daily. The patient showed remarkable response, with lesions decreasing in size.
The patient returned to the WLAMC with multiple ulcerated lesions on his face, chest, back, and extremities and hair loss, which he reported all began within weeks of starting erlotinib. Later, he also developed trichomegaly, also presumed to be a consequence of erlotinib. Despite these AEs, erlotinib was continued at the same dose, given his impressive response to this treatment, the absence of response to other therapy, and the patient’s insistence on continuing the medication.
Of note, after his transition to the outside hospital, Mr. J and his family paid all his medical expenses because he had no insurance. His family was very supportive, and the patient described their motivation and support as paramount in his receiving treatment.
In 2008, Mr. J presented to a dermatologist and was treated with cleocin solution. Although this helped to control his symptoms, the rash persisted. As a complication of these lesions, he also experienced several superinfections for which he was treated with cephalexin. At this same time, a PET scan showed no evidence of disease. He presented to the pain service for persistent chest wall pain around the surgical site, and his pain regimen was changed to slow-release morphine 200 mg 3 times per day and morphine sulfate solution 20 mg/mL 80 mg every 4 hours for breakthrough pain.
The PET scans, which were repeated every 3 months after Mr. J resumed treatment at WLAMC, showed continued absence of disease. In 2009, when he presented to the hospital with pneumonia, a PET scan showed 2 new areas of tracer uptake measuring 1 cm. His chest wall was irradiated, but radiation therapy was stopped after the biopsy returned benign. In 2015, an annual PET scan showed only evidence of postsurgical changes.