2. Clinical Case
A 46-year-old Japanese woman with a 12-pack/year smoking history with no asbestos exposure, presented with a chronic dry cough at a neighborhood hospital. Her chest images showed diffuse thickening of the right pleura with pleural effusion (Fig. 1A–C). After excluding infectious diseases, she was suspected to have a malignant disease, because of the positive cytology of her right pleural effusion. A percutaneous right-pleural biopsy examination revealed stage IV (T4N2M1a) non-Sq NSCLC (Fig. 2A, B) with immunostaining was positive for Ber-EP4 (Fig. 2C) and slightly positive for CEA (data not shown) as carcinoma markers, and negative immunostaining for calretinin (Fig. 2D) and D2-40 (data not shown) as mesothelioma markers. In that hospital, she was first treated with gefitinib, an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, as non-Sq NSCLC in a young Japanese woman might reasonably be expected to have an EGFR mutation. However, her tumor did not improve, and was subsequently found to have no EGFR mutation. Gefitinib treatment was stopped after four weeks.
For her second-line treatment, she was referred to our hospital. On admission, drainage to her right pleural space was not feasible, as the prolonged pleural effusion had produced a sclerosing tumor. As systemic chemotherapy, cisplatin (75 mg/m2) and pemetrexed (500 mg/m2) were started, which led to a good partial response after the second cycle, as shown by computed tomography (Fig. 3A,B). Bevacizumab was suggested but not added to this regimen, due to patient’s refusal in consideration for its adverse effects (AEs). She received PMT (500 mg/m2, every 21 or 28 days) followed by four cycles of the induction regimen of cisplatin and pemetrexed, and her pleural lesion continued to diminished, resulting in a CR at the 29th PMT cycle (Fig. 3C, D). Her serum carcinoembryonic antigen (CEA) had been elevated (198 ng/mL at its zenith) during her second-line treatment, but had normalized with the success of PMT. She had not suffered any severe AE that would have required stopping chemotherapy, but did experience grade 2 hepatic dysfunction and grade 1 edema.
Although PMT was stopped at the 32th cycle at her insistence, she has retained a durable CR without recurrence for 73 months to date (Fig. 4A–D). She has survived for eight-and-a-half years from the diagnosis of advanced non-Sq NSCLC, and has remained disease-free without drug therapy for six years.