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.