44 year old male, non-smoker with no comorbidities, presented to us with complains of cough for 6 months and fever for 2 months. His CT scan was done from outside hospital which showed a heterogeneous left lower lobe mass with few adjacent tiny nodules and significant adjacent thickened pleura. He had underwent biopsy of the lesion which revealed poorly differentiated carcinoma with features favoring pleomorphic carcinoma of lung.
His histopathology was reviewed at the hospital and showed Adenocarcinoma Grade III, TTD-1 positive, Synoptophysin Negative. His Staging PET CT scan was done in house which remonstrated a hyper-metabolic left lower lobe lung mass 7.2cm in size with mediastinal and left level IV cervical lymphadenopathy. There was no evidence of FDG avid visceral or osseous metastases. His final staging according to AJCC 8th edition was T4N3M0 disease.
He was discussed in MDT and was recommended to undergo induction chemotherapy for 2 cycles followed by response assessment. Patient was offered 2 cycles of cisplatin 75mg/m2 and Pemetrexed 500mg/m2. His response assessment scan showed partial treatment response. He was then offered concurrent chemo-radiation 55 Gray in 20 fractions with Cisplatin 100mg/m2 on Day 1 and Vinorelbine 50mg/m2 on Day 1 8 and 15. Patient has a near complete response to treatment and remained on follow up with his subsequent scan showing no recurrent disease
After 8 months post treatment he developed pain in right side of abdomen radiating to the back. His CT abdomen was performed which showed a progressive soft tissue mass in para duodenal /peri-pancreatic area inseparable from uncinate part of pancreas. His Endoscopic ultrasound and biopsy of the lesion was done. Histopathology showed Metastatic Adenocarcinoma from primary lesion with EGFR mutated at Exon 21 and ALK rearrangement not detected.
Patient was offered palliative Radiation 20 Gray in 5 fraction for pain control to pancreatic mass and was offered Erlotinib 150mg once daily. There was significant response to treatment clinically and radiologically. Post 6 months there was no residual disease left. Patient remained on follow up till now