Surgical resection of advanced non-small cell lung cancer after a response to EGFR-TKI: presentation of two cases and a literature review

Abstract

Background: The usefulness of residual tumor resection after epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) treatment remains unclear. We describe two patients who underwent residual tumor resection after responding to EGFR-TKIs for advanced non-small cell lung cancer (NSCLC) harboring EGFR gene mutations, along with a review of the literature.

Case presentation: The patient in Case 1 was a 72-year-old female non-smoker who was initially diagnosed with T2aN2M0, stage IIIA adenocarcinoma harboring an EGFR exon 21 L858R mutation. After 8 months of gefitinib therapy, a marked radiologic response was noted, and right upper lobectomy with systemic lymph node dissection was performed. The patient developed brain metastasis despite continuous gefitinib therapy. The patient in Case 2 was a 68-year-old female non-smoker who was initially diagnosed with T3N2M0, stage IIIA adenocarcinoma and an extensive pulmonary thromboembolism. After 3 months of therapy with afatinib and anticoagulants, a marked radiologic response and symptom relief were achieved. We then performed right bilobectomy with systemic lymph node dissection. She developed bone metastasis despite postoperative afatinib therapy.

Conclusion: The timing and validity of salvage surgery for residual lesions remain unclear when TKIs are offered as first-line therapy to patients with advanced NSCLC. In our two cases, surgery was performed without any complications. Surgical resection of the residual tumor might contribute to good local control. The accumulation of more clinical data is needed to further investigate the role of surgery in patients with advanced NSCLC harboring EGFR gene mutations.

Keywords: EGFR mutation; EGFR-TKI; Non-small cell lung cancer; Surgery.

Fig. 1

Case 1. PET-CT showing the high fluorodeoyglucose (FDG) uptake of the primary lesion and swelling of the #2 (a) and #4 lymph nodes (b) before gefitinib therapy. PET-CT showing the regression of the primary lesion and the #2 (c) and #4 (d) lymph nodes after gefitinib therapy. Histological findings (hematoxylin-eosin staining) showing residual viable tumor cells in the primary lesion (e-f)

Fig. 2

Case 2. Chest CT showing a primary lesion in the right lower lobe (a), a 10-mm nodule in the right S6, and right middle lobe atelectasis due to bulky hilar and subcarinal lymph nodes (b) before afatinib treatment. Chest CT showing the marked regression of both the primary tumor (c) and lymph node metastases, with the disappearance of middle-lobe atelectasis (d) after afatinib therapy. Histological findings (hematoxylin-eosin staining) showing the prominent proliferation of fibroblasts (e); residual viable tumor cells were found in a small area of the primary lesion (f)