CBDCA + Pemetrexed + Bevacizumab and Its Maintenance Chemotherapy in a Case of Solitary Breast Metastasis from a Lung Adenocarcinoma Resistant to Gefitinib

Abstract

Based on the AVAPERL trial (36th ESMO 2011), CBDCA + pemetrexed + bevacizumab and its maintenance chemotherapy with pemetrexed + bevacizumab is a new promising regimen for the treatment of advanced non-small-cell lung adenocarcinoma. Herein, we report the rare case of a patient with solitary breast metastasis from a lung adenocarcinoma, which was effectively treated using CBDCA + pemetrexed + bevacizumab and its maintenance chemotherapy. A 57-year-old female was admitted to the hospital due to pleural effusion and cardiac tamponade caused by a lung adenocarcinoma possessing a mutation of the epidermal growth factor receptor (EGFR) gene (deletion of exon 19). The patient was treated by first-line chemotherapy (gefitinib 250 mg/body/day) which resulted in complete response. After 12 months, carcinoembryonic antigen was gradually increasing and she complained of a right breast mass. With a core-needle biopsy, the breast tumor was pathologically diagnosed as recurrence and solitary metastasis of a lung adenocarcinoma. Further study of the second mutation of EGFR revealed a T790M mutation. The patient was treated by second-line chemotherapy [CBDCA + pemetrexed + bevacizumab (AUC 6 + 500 mg/m(2) + 15 mg/kg)] and its maintenance chemotherapy (pemetrexed + bevacizumab). The cases of patients with breast metastasis from other organs are very rare. Immunohistopathological analysis is very useful to diagnose whether the malignancy is primary or not. In the case of a breast tumor with present or previous malignancy, a metastatic breast tumor should be considered. Furthermore, the biopsy of the breast metastasis also revealed the second mutation of resistance to gefitinib, T790M. Of note, according to our case, CBDCA + pemetrexed + bevacizumab and its maintenance chemotherapy is feasible and well tolerated for breast metastasis from a lung adenocarcinoma which is resistant to gefitinib and possesses the T790M mutation in the EGFR gene.

Keywords: CBDCA + pemetrexed + bevacizumab; Maintenance therapy; Non-small-cell lung carcinoma; Solitary breast metastasis; T790M; Tyrosine kinase inhibitor resistance.

Fig. 1

X-ray, CT and cytopathological findings. a X-ray on admission. b, c CT on admission. d Papanicolaou stain of pleural effusion. e, f CT after first-line chemotherapy. g Mammography at recurrence. h Chest CT of the breast at recurrence. i Scintigraphy at recurrence. j Mammary ultrasonography of the right breast at recurrence. k Ultrasonography of the right axillary at recurrence.

Fig. 2

Pathological analysis of the needle biopsy. a Hematoxylin-eosin staining. Immunostaining of CK7 (b). CK20 (c), TTF-1 (d), SP-A (e), MUC1 (f), MUC2 (g), GCDFP15 (h), ER (i), PgR (j) and HER2 (k).

Fig. 3

a Mammary ultrasonography of the right breast after second-line therapy. b Ultrasonography of the right axillary after second-line therapy. c Chest CT of the breast after second-line therapy.

Fig. 4

Overview of the therapy and change of CEA.