|Ahead of print publication
Management and outcome of EGFR mutant lung cancer with SARS-CoV-2 infection
Spoorthy Kolluri1, Soumya Surath Panda1, Adyakinkar Panda2, Santosh Kumar Singh3
1 Department of Medical Oncology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
2 Department of Radiology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
3 Department of Medicine, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
|Date of Submission||22-Jul-2021|
|Date of Acceptance||06-Sep-2021|
|Date of Web Publication||27-Apr-2022|
Department of Medical Oncology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
The world and India, in particular, have been grappling with the coronavirus disease (COVID-19) pandemic for more than a year now. The simultaneous presence of active COVID-19 infection with lung cancer poses both a diagnostic and therapeutic dilemma, because of similar clinical, radiological features along with increased susceptibility to ICU admissions and death. We present the case of a metastatic EGFR mutant lung cancer patient who was started on Gefitinib during active COVID-19 infection. He had made a complete recovery from COVID-19 infection while achieving a partial response to therapy in terms of primary lung cancer. The case highlights the importance of active involvement of a medical oncologist in the care of all cancer patients with COVID-19 infection instead of the traditional holding of all therapy for cancer until COVID-19 recovery as suggested by the majority of guidelines.
Keywords: COVID-19, EGFR mutant lung cancer, tyrosine kinase inhibitors
| > Introduction|| |
The global coronavirus disease (COVID-19) pandemic has had a devastating impact on healthcare worldwide, particularly in India, with over 30,362,848 and 398,484 deaths cases over the two waves at the time of writing this case report. India's cancer care and research during the second wave, has been challenging due to the lack of clear guidelines regarding the management of cancer patients testing positive for COVID-19. The unpredictable lockdowns and surge of cases have lead to the increasing number of patients coming with advanced and metastatic disease in the country. Cancer patients contributing to 2% of total COVID-19 patients are particularly susceptible to COVID-19 infection and have a poorer prognosis compared to the general population. Lung cancer patients in particular, pose both a diagnostic and therapeutic dilemma, because of similar clinical features such as cough, dyspnea, and radiological features like ground-glass opacities resembling lymphangitis carcinomatosis, at presentation. While most guidelines suggest holding chemotherapy and immunotherapy during active COVID-19 infection, data on the use of tyrosine kinase inhibitors (TKIs) in Oncogene addicted lung cancer are unclear. Here, we report a case of a patient with EGFR mutant lung cancer, who was managed by starting chemotherapy initially followed by the addition of TKI during active COVID-19 infection.
| > Case Report|| |
A 41-year-old, nonsmoker presented to us in April 2021 with cough, hemoptysis, and shortness of breath. A positron emission tomography-computed tomography (CT) showed a right upper lobe mass of size 3.48 cm × 2.6 cm with SUVma × 9.4 with right upper and middle lobe lymphangitis carcinomatosis, moderate right pleural effusion, and enlarged mediastinal lymph nodes the largest being 3.5 cm × 3.7 cm with SUVma × 5.4 [Figure 1]. The patient underwent CT-guided biopsy of the lung mass. Histopathological examination revealed nonsmall-cell lung cancer and immunohistochemistry showed nuclear TTF-1 and cytoplasmic Napsin-A positivity which was suggestive of adenocarcinoma. The tissue was sent for molecular testing. As the patient was symptomatic for the disease, he was started on chemotherapy with Pemetrexed (500 mg/m2) and carboplatin (AUC-5) chemotherapy, before the results of the molecular tests arrived. On day 8 of chemotherapy, the patient presented with fever and increasing dyspnea. He was found to have Grade-IV neutropenia and tested positive for SARS COV-2 on reverse transcription polymerase chain reaction. The patient was admitted to the ICU in view of decreased saturation at room air and needed to be put on noninvasive ventilation (NIV). Meanwhile, the results of the molecular testing became available and the patient tested positive for EGFR Exon 19 mutation. He was started on Gefitinib immediately postadmission. The patient received steroids and Remedesivir (loading dose of 200 mg, followed by 100 mg/day for 4 days) for the management of viral pneumonia. High-resolution computed tomography (HRCT) showed extensive viral pneumonia in all lobes with a CT severity score of 14/25 [Figure 2]. He made a steady recovery during his hospital stay. NIV and oxygen support were completely weaned off 15 days after testing positive for SARs-COV-2. HRCT postrecovery showed resolution of viral pneumonia with partial response in the primary cancer lesions in the form of reduced lung mass and reduction in lymphangitis carcinomatosis features [Figure 2].
|Figure 1: Positron emission tomography-computed tomography study at diagnosis. Homogenously enhancing mass lesion seen apical segment of the right lung. Large confluent subcarinal (level 7) node is also seen (asterix) along with features of lymphangitis carcinomatosis|
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|Figure 2: High-resolution computed tomography at diagnosis showed extensive consolidations with computed tomography severity score of 14/25. Computed tomography study at discharge showed reduction in lung mass, lymphangitis carcinomatosis features, and COVID lesions|
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| > Discussion|| |
Lung cancer patients represent a special population among those infected with SARs CoV2, due to increased susceptibility for the need of critical care and death attributable to the presence of risk factors such as older age, smoking history, chemotherapy, poor performance status seen routinely this population. This is reflected in the data from the COVID-19 and Cancer Consortium (CCC19) where lung cancer mortality contributed to a towering 26% mortality rate compared to the 16% overall mortality rate for all cancers, despite contributing to 10% of all cancer patients infected with COVID-19. The TERAVOLT (Thoracic Cancers International Covid19 Collaboration) registry reported a high mortality rate of 34.6% among patients with thoracic malignancies. Most of the deaths reported were due to COVID-19 infection and not cancer, supporting the guidelines advocating for the delay in cancer treatment. However, the study also noted that cancer treatments including TKI's were not associated with increased mortality in these patients. Hence, maybe the concomitant use of TKIs in these patients may prevent unwarranted progression of cancer. Moreover, EGFR TKIs like Erlotinib have been proposed as potential drugs in the management of viral fevers associated with cytokine storms, by altering the cytokine response However, there is also concern that EGFR TKI-induced ILD may aggravate the patients' clinical condition.
There have been other case reports where EGFR TKI's and ALK TKI's were continued in patients with active COVID 19 infections, but patients in these reports had mild infection and did not require intensive care, unlike our patient., The factors favoring the good response in our patient could be the younger age and nonsmoker status and results may be different for older patients who are smokers. However starting and continuing TKI therapy in driver mutated lung cancer warrants further studies.
| > Conclusion|| |
Active involvement of cancer specialists in the care of cancer patients throughout the COVID-19 infection might reduce the chance of unwarranted progression of cancer following recovery from COVID-19. Furthermore, current guidelines might not reflect the dynamic nature of cancer care during the COVID-19 pandemic and every case needs individualization until more evidence emerges on definitive management of cancer care in the current scenario.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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