Left Upper Lung Mass Research Articles

Abstract 3343: Durable response to osimertinib monotherapy as first line treatment in stage IVB lung adenocarcinoma with atypical EGFR L747P mutation

Abstract Background: Targeted therapy plays a critical role in NSCLC with a certain type of mutation. Osimertinib is a third generation EGFR tylosine kinase inhibitor (TKI) which is primarily indicated for NSCLC with EGFR exon 19 deletions or exon 21 L858R mutations. Although use of osimertinib is currently limited to patients with common EGFR mutations, it has been reported that patients with NSCLC harboring uncommon EGFR mutations demonstrated response to EGFR TKIs. Herein, we present a case of advanced adenocarcinoma of the lung with atypical EGFR L747P mutation that revealed a noteworthy durable response to osimertinib monotherapy as first line treatment. Case presentation: A 47-year-old woman with no smoking history presented with new-onset hemoptysis and cough. A chest CT scan showed a lobulated, spiculated 38 mm left upper lung mass with innumerable bilateral pulmonary nodules. CT-guided biopsy demonstrated adenocarcinoma of lung with PD-L1 1-2%. Subsequent PET-CT scan revealed hypermetabolic neoplasm in the left lower lobe with scattered area of abnormal focal FDG uptake within the liver. Brain MRI showed unremarkable findings. The patient was diagnosed with stage IVB adenocarcinoma of lung with multiple hepatic metastases. Circulating tumor DNA (ctDNA) NGS assay showed EGFR L747P [0.3% of variant allele frequency (VAF)] and tissue NGS assay revealed EGFR L747P missense variant c.2239_2240delinsCC (22.8% of VAF). The patient was started on osimertinib 80 mg daily. Follow up CT scan in six week demonstrated decrease in size of the left lower lobe lung mass to 32 mm. She has maintained durable SD for six months without any adverse effects. Most recent follow-up CT scan after eight months from the treatment demonstrated SD of the mass in the left lower lobe and less prominent numerous pulmonary nodules. Discussion: It has not been reported that osimertinib monotherapy is used as first line therapy in NSCLC with EGFR L747P mutation. We report the case of durable response to osimertinib in patients with advanced NSCLC with EGFR L747P mutation. Our case highlights the potential efficacy of osimertinib to NSCLC with atypical EGFR mutation. Although there was a clinical trial to explore clinical activity of osimertinib in patients with NSCLC harboring uncommon EGFR mutation, EGFR L747R mutation was not investigated at that time. To date, there are no ongoing clinical trials on the use of osimertinib in NSCLC with EGFR L747P mutation. Further investigations are warranted to confirm the efficacy of osimertinib in this type of mutation. Citation Format: Horyun Choi, Yeun Ho Lee, Jinah Kim, Leeseul Kim, Na Hyun Kim, Young Kwang Chae. Durable response to osimertinib monotherapy as first line treatment in stage IVB lung adenocarcinoma with atypical EGFR L747P mutation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3343.

ATRIAL FLUTTERS AS AN INITIAL PRESENTATION OF LUNG CANCER CAUSING MALIGNANT PERICARDIAL EFFUSION

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pericardial effusion is a devastating cardiac condition, resulting from various etiology. Cardiac arrhythmia is an uncommon presentation of pericardial effusion, while atrial fibrillation is the most common arrhythmia found in this condition. Atrial flutter, as an initial presentation of malignant pericardial effusion, has not yet been reported. We presented a case of an elderly man with atrial flutter from malignant cardiac effusion from a newly diagnosed lung cancer. CASE PRESENTATION: An 81-year-old man, with chronic obstructive pulmonary disease and hypertension, presented with acute onset shortness of breath. He used albuterol MDI but his symptoms were not improved. On evaluation, he had heart rate 179 beats per minute (bpm), blood pressure 172/118 mmHg without pulsus paradoxus, and respiratory rate of 26. He had good mental status and did not have jugular venous distention. Lungs exam was normal. Heart exam revealed tachycardia without murmur. His blood test was unremarkable. His ECG showed atrial flutter with rapid ventricular rate and 2:1 block. He received intravenous Diltiazem 20 mg and his heart rate decreased to 90. Point of care ultrasound (POCUS) showed large pericardial effusion without tamponade physiology and no signs of pulmonary edema. Computed tomography (CT) chest illustrated large pericardial effusion with new left upper lung mass. Cytology from pericardial effusion revealed squamous cell carcinoma. He was diagnosed as malignant pericardial effusion from advance stage squamous cell lung cancer. His hospital course was complicated with septic shock and eventually death. DISCUSSION: Lung cancer is the most common metastasis cancer to the heart and pericardium because of the proximity of the tumor to the heart [1]. There are several possible explanations of malignant pericardial effusion pathogenesis. First, it can be a result of cardiac lymphatic drainage occlusion by the tumor [2]. Second, local or hematogenous spread of the tumor lead to venous blood flow obstruction and an increase in hydrostatic pressure causing pericardial effusion [3]. Third, neoplastic pericardial involvement stimulates an overproduction of pericardial fluid [3]. Pericardial effusion in cancer patients may arise from complications of treatment, including chemotherapy and radiation, and hypoalbuminemia from malignancy-related cachexia. Cytology analysis of pericardial fluid and pericardial biopsy should be performed to confirm the diagnosis. Management includes pericardiocentesis, pericardial window, pericardial sclerosis, and radiation therapy. CONCLUSIONS: We presented a rare case of atrial flutter secondary to malignant pericardial effusion from newly diagnosis of advanced-stage lung cancer. Clinicians should have pericardial effusion as a differential diagnosis of patients with atrial flutter as this is a catastrophic condition, requiring urgent management. Reference #1: DeCamp MM, et al. Malignant effusive disease of the pleura and pericardium. Chest. 1997;112(4 Suppl):2915-2955. Reference #2: Chiles C, et al. Metastatic involvement of the heart and pericardium: CT and MR imaging. Radiographics. 2011;21(2):438-449. Reference #3: Scheinin SA, Sosa-Herrera J. Cardiac tamponade resembling an acute myocardial infarction as the initial manifestation of metastatic pericardial adenocarcinoma. Methodist Debakey Cardiovasc J. 2014; 10:124–128. DISCLOSURES: No relevant relationships by Nehad Shabarek, source=Web Response No relevant relationships by Kulachanya Suwanwongse, source=Web Response

S59. Response to immunotherapy in antibody-negative autoimmune epilepsy

Introduction Autoimmune epilepsy has been linked to a number of neural specific antibodies and the diagnosis is generally established by identifying one of these antibodies. Recognizing an autoimmune etiology is important because the mainstay of treatment is immunotherapy rather than anti-seizure drugs. However, antibodies may not always be detected and a clinical response to immunotherapy can support the diagnosis. We present a patient who showed significant improvement after immunotherapy even though no antibodies were detected. Methods Case report. Results 79 year old woman with history of breast cancer developed tremors, cognitive issues and generalized tonic-clonic seizures. MRI brain was unremarkable. EEG revealed frontal- temporal sharp waves and diffuse slowing. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis and raised protein. She gave a history of tick exposure and family members had Lyme disease. Lyme screening assay was positive for IgG, but IgM was negative. Testing for Epstein Barr virus, cytomegalovirus, herpes simplex virus, toxoplasma, Neurosyphilis, Gram stain and fungus culture was negative. Paraneoplastic panel (serum and CSF) and autoimmune panel including NMDA, GAD, and AMPA receptors were also negative. Heavy metal screening for arsenic, mercury, lead and copper was negative. Neuron specific enolase and 14-3-3 studies were unremarkable. Her seizures responded to fosphenytoin, and she was later switched to levetiracetam. She was treated with a course of ceftriaxone for presumed Neuroborreliosis. She improved clinically and was discharged. One month later, the patient returned with worsening tremors, cognitive dysfunction and seizures. She underwent extensive testing for etiology including MRI and CSF studies, which were unremarkable. Paraneoplastic/autoimmune panel was again negative. EEG showed temporal sharp waves and slowing. CT chest/abdomen/pelvis revealed a lung mass concerning for a malignancy. The patient was presumed to have a paraneoplastic syndrome due to history of cancer and new left upper lung mass, and was treated with IVIG. She had significant clinical improvement with resolution of seizures, and improvement in tremors and cognitive dysfunction. She is currently status post 7 treatments of IVIG without any relapse for >6 months. EEG was repeated and revealed resolution of slowing and sharp wave activity. Conclusion Although extensive testing for paraneoplastic and autoimmune antibodies was negative in our patient, the significant clinical and EEG response to immunotherapy with IVIG confirmed the diagnosis of autoimmune epilepsy. Since not all antibodies have been described and not all the described antibodies have commercially available testing, negative results do not exclude the possibility of autoimmune epilepsy. A trial of immunotherapy is warranted in such cases, if there is strong clinical suspicion.

Biopsy-Proven Transitional Cell Carcinoma of a Lung Mass Without an Urothelial Origin - A Rare Case Report

A 77-year-old man with smoking history visited Thoracic Surgery department with a complaint of dry cough and dyspnea for months. Chest CT showed a mass over left upper lobe, mediastinal lymph node enlargement and bilateral lung nodules. CT-guide biopsy of the left upper lung mass revealed transitional cell carcinoma. Nevertheless, no primary origin was discovered after a thorough evaluation of genitourinary tract, including abdominal CT, FDGPET, cystoscopy and retrograde pyelography. We will discuss the possible reasons for the unknown primary origin of transitional cell carcinoma in a lung mass.

Lung Parasite Ova Granuloma Mimicking Lung Malignancy on FDG PET-CT

A 60-year-old lady with mild fever, blood tinged sputum, and a left upper lung mass had whole body F-18 2-deoxy-D-glucose (FDG) positron emission tomography (PET)-computer tomography (CT) for cancer staging. The PET-CT imaging revealed FDG accumulation in the left upper lung lesion. The histopathology of the left upper lobe lung resection showed a parasite tunnel with necrosis, parasite ova, and foreign body giant cells. After surgery, eosinophiles in the peripheral blood dropped from 20% of white cell counts before operation to 5.5% at 7 weeks postoperation.