• In this unusual case, a 42-year-old woman presented with general malaise and anorexia for the past 3 months. The initial evaluation indicated advanced right upper lung cancer with multiple brain and bone metastases. Staging was T1bN3M1b, stage 4B. Her labs indicated disseminated intravascular coagulation (DIC) induced by advanced lung cancer.
• This rare presentation is due to severe lung adenocarcinoma exhibiting EGFR mutations and EML4-ALK rearrangements with DIC. Typically these mutations are mutually exclusive, with co-occurrence reported in only 0.9%–1.3% of EGFR mutation-positive NSCLC patients. Intriguingly, EGFR-TKIs and ALK-TKIs can prove effective for patients harboring both EGFR mutation and EML4-ALK rearrangement, although it is unclear which drug to start with.
• The authors made two notable points. “First, [o]simertinib, a third-generation EGFR-TKI, showed a favourable tumour response. Despite the controversy regarding the use of EGFR-TKI as first-line treatment, our patient benefitted from its use. Second, osimertinib could quickly overcome severe conditions as represented by the DIC in this patient. In general, clinicians often hesitate to induce cytotoxic chemotherapy for lung cancer patients with severe DIC because these patients are thought to have no tolerance. Molecular targeting agents such as EGFR-TKIs and ALK-TKIs are good choices for patients with severe clinical conditions.”
• The take-home message is that even with guarded presentations, third-generation EGFR-TKIs may be employed in those with multiple sensitive driver oncogene alterations.
doi: 10.1016/j.rmcr.2021.101393. 1 Division of Respiratory Medicine, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, 1-1 Fukakusa-Mukaihata, Fushimi-Ku, Kyoto, Japan. 2 Department of Respiratory Medicine, Ijinkai Takeda General Hospital, Kyoto, Japan. Free PMC article Free PMC article doi: 10.1016/j.rmcr.2021.101393.