Case reportSuccessful empirical erlotinib treatment of a mechanically ventilated patient newly diagnosed with metastatic lung adenocarcinoma
Introduction
Lung cancer is the leading cause of cancer-related deaths worldwide and is the second most common cancer in both men and women [1]. Non-small-cell lung cancer (NSCLC) comprises up to 90% of all lung cancers, and the majority present with advanced or metastatic (stage IV) disease. Although smoking is the leading risk factor for lung cancer, 15–20% of lung cancers occur in patients who have never smoked [2]. Nearly half (49%) of patients who have never smoked and up to 42% of former light smokers (1–10 pack-years smoking history) with metastatic lung adenocarcinoma present epidermal growth factor receptor (EGFR) activating mutations [3]. Tumors that harbor EGFR mutations can present dramatic responses to first-line treatment with an EGFR tyrosine-kinase inhibitor (TKI), such as erlotinib [4], [5], gefitinib [6] or afatinib [7].
Lung cancer is the most common solid tumor in critically ill cancer patients with cancer- or treatment-related complications who are admitted to ICUs [8]. The most common reason for ICU admission in these patients is respiratory failure, which necessitates mechanical ventilation. Despite recent improvements in the intensive care of critically ill cancer patients, the outcome of patients with lung cancer who are admitted to the ICU is poor, especially in those requiring mechanical ventilation as a result of respiratory failure [9]. Although several studies over the last decade have reported a progressive improvement in the outcome of lung cancer patients who are admitted to ICUs, it is clear that not all lung cancer patients will benefit from this aggressive care [10], [11].
In some patients with cancer, the usual ICU admission triage criteria may be unreliable [7]. More recently, the criteria has expanded for qualification to an ICU trial and includes those patients who are newly diagnosed with cancer but with a life expectancy of less than 1 year [10]. The ICU trial consists of unlimited ICU support for a limited time period, and the parameters needed for the study are collected for at least 3–5 days [12].
Here, we present the case report of a newly diagnosed patient with metastatic lung adenocarcinoma who required mechanical ventilation due to respiratory failure caused by the disease. Based on clinical data, a high probability of EGFR mutation was suspected, and thus, empirical treatment with erlotinib was administered as a part of the ICU trial. This represents the first case report of successful empirical treatment with erlotinib in an ICU setting.
Section snippets
Case report
A 60-year-old Caucasian female former light smoker (<10 pack-years consumption) presented with a history of toxic syndrome and progressive dyspnea in November 2013. A contrast-enhanced computed tomography (CT) scan revealed a bilateral interstitial nodular pattern, right pleural effusion, and a lower right lobe mass (Fig. 1). A bronchoscopy was performed with transbronchial biopsy. Patient's condition worsened with progressive respiratory failure and she was transferred to the ICU, where
Discussion
Although the primary reasons for admission to the ICU are related to treatment and to other complications associated with cancer, some patients are admitted to the ICU before a cancer diagnosis is well-established or immediately after a recent diagnosis. The decision to initiate chemotherapy in critically ill cancer patients is extremely complex, especially in patients who are admitted to the ICU. The benefit of chemotherapy treatment in the ICU has primarily been explored in patients with
Conclusion
This report provides insight into a successful empirical treatment with erlotinib in an ICU patient with newly diagnosed metastatic lung adenocarcinoma. Although the patient required critical support, a dramatic and durable response was obtained with the treatment. This case report represents a proof-of-concept of the necessity of a multidisciplinary approach to treating cancer patients in an ICU with the appearance of new, targeted agents against this disease in clinical practice.
Conflict of interest statement
All authors have no conflicts of interest.
Acknowledgement
Joaquim Bosch-Barrera is supported by an Emerging Research Grant 2013 from the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica, Madrid, Spain).
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- 1
Both authors contributed equally to this work.