Abstract
Introduction: Adenocarcinoma of the lung is the most common subtype of non-small cell lung cancer, and epidermal growth factor receptor (EGFR) mutations are the most common driver genes in the development of cancer (NSCLC). Among them, mutations in exons 18–21 are the most frequent, especially the deletion of exons 19 and 21, where L858R mutations are the most common. Other mutations such as S768I, G719X, and 20ins are relatively rare. In the population of lung adenocarcinoma patients with EGFR mutations, some common mutations may occur, especially TP53. Case Presentation: Here, this study presents a retrospective analysis of neoadjuvant therapy for lung adenocarcinoma and reviews relevant literature. The patient was diagnosed with T4N3M1a, stage IVa. After 1 month of chemotherapy with 860 mg of pemetrexed and 480 mg of carboplatin, and immunotherapy with 200 mg of sintilimab, good response to conventional chemotherapy, but a follow-up CT scan showed disease progression. Next-generation sequencing showed EGFR exon 20 missense mutation (p.S768I and p.V774M) combined with tumor protein p53 (TP53) (p.Y220C) missense mutation, with mutation abundance of 48.6%/49.7% and 49.2%, respectively. Subsequently, chemotherapy with paclitaxel albumin 400 mg and treatment with pembrolizumab 200 mg were administered, followed by targeted treatment with oral afatinib (PFS: 12 months). And then, brain metastasis occurred, and targeted treatment with osimertinib was used instead (PFS: 9 months). The therapeutic effect is significant, but due to severe side effects, the patient stopped taking the medication on their own. Five months later, the patient became seriously ill again and CEA levels increased. Targeted treatment with furmonertinib (PFS: 3 months) and sunvozertinib (PFS: 3 months) was used instead. Three months later, the blood CEA level briefly decreased and then continued to increase, indicating the patient’s critical condition. Conclusion: The results indicate that targeted therapy with afatinib and osimertinib for EGFR S7688I/V774M and TP53 mutations has better PFS than targeted therapy with furmonertinib and sunvozertinib. Simultaneously, the combination of platinum-based chemotherapy and immunotherapy may be a potential neoadjuvant therapy for NSCLC IVa stage patients.
Introduction
Lung cancer remains the most common cancer (accounting for 11.6% of all cancers) and is the leading cause of cancer-related mortality due to the majority of patients being diagnosed in the late stages [1‒3]. In 2018, the global death toll from lung cancer exceeded 1.7 million. Non-small cell lung cancer (NSCLC) accounts for more than 80% of the incidence rate of lung cancer, of which lung adenocarcinoma is the most common subtype [4, 5]. Guidelines for diagnosis and treatment of lung cancer recommend genetic testing for advanced NSCLC patients to guide targeted therapy. Epithelial growth factor receptor (EGFR) is a receptor for epithelial growth factor (EGF) cell proliferation and signaling and belongs to the ErbB receptor family [6, 7]. High or abnormal expression of EGFR is present in many solid tumors, which is associated with the inhibition of tumor cell proliferation, angiogenesis, invasion, metastasis, and apoptosis. EGFR mutations and tyrosine kinase inhibitors (TKIs) have become the standard-of- care in EGFR-positive patients with advanced lung cancer. 19 deletion (19del) and L858R are the most common mutation sites in the EGFR gene; however, EGFR also has some rare mutation sites, such as S768I, L861Q (<5%), and so on [8‒11].
With the development and application of next-generation sequencing detection technology, more and more co-mutated genes are being discovered. As is well known, co-mutations play an important role in the response and resistance to EGFR-TKI in EGFR mutant NSCLC. Common co-mutated genes include TP53 mutations, MET gene alterations, ALK rearrangements, and so on. TP53 is an important tumor suppressor gene in cells, and it has the highest mutation frequency (>50%) among various types of tumors, including lung adenocarcinoma and lung squamous cell carcinoma. EGFR-TP53 co-mutation, as the most common type of co-mutation in advanced NSCLC, urgently needs to understand the relationship between EGFR-TP53 co-mutation and EGFR-TKI efficacy and prognosis and guide clinical doctors to choose the best treatment strategy for this group of patients.
Here, we report a rare case of adenocarcinoma patient carrying EGFR S768I/V774M and TP53 dual mutations. Little is known about its clinical manifestations, prognostic value, and efficacy prediction of different treatment plans.
Case Presentation
A 52-year-old male was admitted to the First Affiliated Hospital of Zhejiang University School of Medicine on April 13, 2021, due to intermittent cough for more than half a year and occasional cough with little white sticky phlegm. A CT scan from an external hospital shows a left lung mass. HRCT scan of lung on April 8, 2021: left lung mass, peripheral lung cancer with adjacent left lung metastasis considered (Fig. 1a). EBUS detected lymph node enlargement in groups 7 and 11L, and TBNA was performed on lymph nodes in groups 7 and 11L. Ultrasound bronchoscopy: a subbranch of the left lower basal segment is visible and occupied, and EBUS-TBLB is given. Pathological diagnosis: (left lower lung basal segment puncture tissue) lung adenocarcinoma. Immunohistochemistry: CK7 (+), TTF-1 (+), Napsin A (+), P40 (−), CgA (−), Syn (−) Ki-67 (approximately 10%+). PD-L1 immunohistochemistry: TPS around 10% (Table 1; Fig. 2). Our hospital’s diagnosis is lung adenocarcinoma T4N3M1a, stage IVa.
CT images of patients at different stages. a The maximum diameter of the tumor was 45*30 mm – April 23, 2021. b The maximum diameter of the tumor was 52*38 mm – September 13, 2021. c The maximum diameter of the tumor was 31*22 mm – November 3, 2021. d The maximum diameter of the tumor was 10*8 mm – July 10, 2023. e The maximum diameter of the tumor was 15*13 mm – November 23, 2023. f The maximum diameter of the tumor was 12*11 mm – January 16, 2024. g The maximum diameter of the tumor was 17*16 mm – March 4, 2024. h The maximum diameter of the tumor was 22*21 mm – April 17, 2024. i The maximum diameter of the tumor was 20*17 mm – June 7, 2024. j The maximum diameter of the tumor was 22*22 mm – July 14, 2024.
CT images of patients at different stages. a The maximum diameter of the tumor was 45*30 mm – April 23, 2021. b The maximum diameter of the tumor was 52*38 mm – September 13, 2021. c The maximum diameter of the tumor was 31*22 mm – November 3, 2021. d The maximum diameter of the tumor was 10*8 mm – July 10, 2023. e The maximum diameter of the tumor was 15*13 mm – November 23, 2023. f The maximum diameter of the tumor was 12*11 mm – January 16, 2024. g The maximum diameter of the tumor was 17*16 mm – March 4, 2024. h The maximum diameter of the tumor was 22*21 mm – April 17, 2024. i The maximum diameter of the tumor was 20*17 mm – June 7, 2024. j The maximum diameter of the tumor was 22*22 mm – July 14, 2024.
Primary antibodies used for immunohistochemical staining
Antibody . | Clone . | Dilution . | Purchased from . |
---|---|---|---|
CK7 | EP16 | 1:300 | ZSGB-Bio, Beijing, China |
TTF-1 | 8G7G 3/1 | 1:1,500 | ZSGB-Bio, Beijing, China |
Napsin A | IP64 | 1:200 | ZSGB-Bio, Beijing, China |
P40 | ZM-0472 | 1:500 | ZSGB-Bio, Beijing, China |
Ki-67 | MIB1 | 1:2,000 | ZSGB-Bio, Beijing, China |
CgA | 5H7 | 1:100 | ZSGB-Bio, Beijing, China |
Syn | ZA-0506 | 1:100 | ZSGB-Bio, Beijing, China |
PD-L1 | 22C3 | 1:40 | Agilent, Beijing, China |
Antibody . | Clone . | Dilution . | Purchased from . |
---|---|---|---|
CK7 | EP16 | 1:300 | ZSGB-Bio, Beijing, China |
TTF-1 | 8G7G 3/1 | 1:1,500 | ZSGB-Bio, Beijing, China |
Napsin A | IP64 | 1:200 | ZSGB-Bio, Beijing, China |
P40 | ZM-0472 | 1:500 | ZSGB-Bio, Beijing, China |
Ki-67 | MIB1 | 1:2,000 | ZSGB-Bio, Beijing, China |
CgA | 5H7 | 1:100 | ZSGB-Bio, Beijing, China |
Syn | ZA-0506 | 1:100 | ZSGB-Bio, Beijing, China |
PD-L1 | 22C3 | 1:40 | Agilent, Beijing, China |
CK, cytokeratin; TTF-1, thyroid nuclear factor 1; CgA, chromogranin A; Syn, synapsin I.
The hematoxylin-eosin (HE) staining and the immunohistochemistry in lung adenocarcinoma. a The hematoxylin-eosin staining revealed that tumor cells were lung adenocarcinoma (×100). b Immunohistochemical examination revealed that tumor cells were positive for monoclonal anti-CK7 antibody (×100). c Immunohistochemical examination revealed that tumor cells were positive for monoclonal anti-NapsinA antibody (×100). d Immunohistochemical examination revealed that tumor cells were positive for monoclonal anti-TTF-1 antibody (×100). e Immunohistochemical examination revealed that tumor cells were negative for monoclonal anti-Ki-67 antibody (×100) (approximately 10%+). f Immunohistochemical examination revealed that tumor cells were negative for monoclonal anti-P40 antibody. g Immunohistochemical examination revealed that tumor cells were negative for monoclonal anti-CgA antibody. h Immunohistochemical examination revealed that anti-Syn antibody. i Immunohistochemical examination revealed that anti-PD-L1 antibody.
The hematoxylin-eosin (HE) staining and the immunohistochemistry in lung adenocarcinoma. a The hematoxylin-eosin staining revealed that tumor cells were lung adenocarcinoma (×100). b Immunohistochemical examination revealed that tumor cells were positive for monoclonal anti-CK7 antibody (×100). c Immunohistochemical examination revealed that tumor cells were positive for monoclonal anti-NapsinA antibody (×100). d Immunohistochemical examination revealed that tumor cells were positive for monoclonal anti-TTF-1 antibody (×100). e Immunohistochemical examination revealed that tumor cells were negative for monoclonal anti-Ki-67 antibody (×100) (approximately 10%+). f Immunohistochemical examination revealed that tumor cells were negative for monoclonal anti-P40 antibody. g Immunohistochemical examination revealed that tumor cells were negative for monoclonal anti-CgA antibody. h Immunohistochemical examination revealed that anti-Syn antibody. i Immunohistochemical examination revealed that anti-PD-L1 antibody.
After excluding relevant contraindications, chemotherapy with pemetrexed 860 mg + carboplatin 480 mg and immunotherapy with xindilimab 200 mg were administered on April 29, May 20, June 12, and July 6, 2021. On July 28, 2021 and August 20, 2021, chemotherapy with 860 mg pemetrexed and immunotherapy with 200 mg xindilimab were administered, and the process went smoothly. CT reexamination showed disease progression, and the treatment plan was changed (Fig. 1b). On September 18, 2021, paclitaxel albumin 400 mg chemotherapy and pembrolizumab 200 mg immunotherapy were administered.
On October 7, 2021, formalin-fixed paraffin-embedded tissues were used for panoramic 425 gene detection of solid tumors, and gene mutation analysis was performed through second-generation sequencing, revealing EGFR gene exon 20 missense mutations (p.S768I and p.V774M) with mutation abundance of 48.6% and 49.7%, respectively. At the same time, the tumor protein p53 (TP53) gene exon 6 missense mutation (p.Y220C) occurred with a mutation abundance of 49.2% (Table 2). Subsequently, on October 12, November 3, and November 24, 2021, the treatment plan was changed to paclitaxel albumin 400 mg + pembrolizumab 200 mg, while oral afatinib-targeted therapy was administered. CT reexamination on November 3, 2021 showed a significant reduction in the size of the lesion (Fig. 1c). On August 26, 2022, the patient’s head MR showed an enlarged lesion and underwent another gamma knife treatment at our hospital. Considering the progression of the patient’s condition, on October 6, 2022, the targeted therapy will be changed to oral Axitinib tablets 1 # qd, but the patient had severe gastrointestinal symptoms and subsequently stopped taking the medication on their own. Lung CT (HR) plain scan on November 23, 2023: multiple patchy and nodular high-density shadows in the left lung, progressing compared to CT scan on July 10, 2023. Lung cancer with multiple metastases in the left lung is considered, and treatment with targeted therapy of Fumatinib 2 # qd is recommended. At this point, after 2 months of targeted treatment with fumatinib, the patient’s clinical symptoms had improved, and a chest CT reexamination suggested improvement of the lesions (Fig. 1e–g). During the 3.5 months of treatment with fumatinib, CT reexamination indicated disease progression, and targeted therapy with sunvozertinib was changed. The level of carcinoembryonic antigen in serum significantly decreased from 7,339.3 ng/mL to 5,686.9 ng/mL (Fig. 3a), and glycoantigen 125 and glycoantigen 199 in serum were also significantly reduced (Fig. 3b, c). Three months of targeted treatment with sunitinib: the CT scan on June 7, 2024 showed a certain degree of lesion shrinkage (Fig. 1g, h). However, 1 month later, the patient experienced persistent high fever with a maximum temperature of 39°C, accompanied by sore throat, cough, sputum, chest tightness, and back pain. Blood test showed a white blood cell count of 10.72*109/L, neutrophils 7.45*109/L, hemoglobin 136 g/L, and high-sensitivity C-reactive protein 38.63 mg/L, aspartate transaminase 161 U/L, total bilirubin 25.2 μmol/L, and glutamyl transpeptidase 1,637 U/L. The CT scan shows lesion progression (Fig. 1i). The patient’s condition is critical, and the family requested discharge in July 2024.
Gene mutation identified by next-generation sequencing of the patient
Gene . | Variation . | Type . | Mutation abundance (%) . |
---|---|---|---|
EGFR | p. S768I exon 20 missense mutation | c.2303G>T (p. S768I) | 48.6 |
TP53 | p.Y220C exon 6 missense mutation | c.659A>G (p.Y220C) | 49.2 |
EGFR | p.V774M exon 20 missense mutation | c.2320G>A (p.V774M) | 49.7 |
MYC | Gene amplification | - | CN:5.3 |
NKX2-1 | Gene amplification | - | CN:25.0 |
NKX2-1 | IGR (downstream FOXA1)-NKX2-1: fusion | IGR (downstream FOXA1)-NKX2-1:exon1 | 9.0 |
ALK | - | Wild type | - |
KRAS | - | Wild type | - |
NRAS | - | Wild type | - |
BRAF | - | Wild type | - |
MET | - | Wild type | - |
ROS1 | - | Wild type | - |
NTRKK1 | - | Wild type | - |
NTRK2 | - | Wild type | - |
NTRK3 | - | Wild type | - |
KIT | - | Wild type | - |
PDGFRA | - | Wild type | - |
RET | - | Wild type | - |
PIK3CA | - | Wild type | - |
ERBB2 | - | Wild type | - |
FGFR2 | - | Wild type | - |
Gene . | Variation . | Type . | Mutation abundance (%) . |
---|---|---|---|
EGFR | p. S768I exon 20 missense mutation | c.2303G>T (p. S768I) | 48.6 |
TP53 | p.Y220C exon 6 missense mutation | c.659A>G (p.Y220C) | 49.2 |
EGFR | p.V774M exon 20 missense mutation | c.2320G>A (p.V774M) | 49.7 |
MYC | Gene amplification | - | CN:5.3 |
NKX2-1 | Gene amplification | - | CN:25.0 |
NKX2-1 | IGR (downstream FOXA1)-NKX2-1: fusion | IGR (downstream FOXA1)-NKX2-1:exon1 | 9.0 |
ALK | - | Wild type | - |
KRAS | - | Wild type | - |
NRAS | - | Wild type | - |
BRAF | - | Wild type | - |
MET | - | Wild type | - |
ROS1 | - | Wild type | - |
NTRKK1 | - | Wild type | - |
NTRK2 | - | Wild type | - |
NTRK3 | - | Wild type | - |
KIT | - | Wild type | - |
PDGFRA | - | Wild type | - |
RET | - | Wild type | - |
PIK3CA | - | Wild type | - |
ERBB2 | - | Wild type | - |
FGFR2 | - | Wild type | - |
–, none.
Treatment of lung adenocarcinoma using different chemotherapy regimens and results of monitoring the CEA levels. The results of using different chemotherapy regimens to treat lung adenocarcinoma and monitoring tumor marker levels. a The results of monitoring the CEA levels. b The results of monitoring the CA125 levels. c The results of monitoring the CA199 levels. CEA, carcinoembryonic antigen.
Treatment of lung adenocarcinoma using different chemotherapy regimens and results of monitoring the CEA levels. The results of using different chemotherapy regimens to treat lung adenocarcinoma and monitoring tumor marker levels. a The results of monitoring the CEA levels. b The results of monitoring the CA125 levels. c The results of monitoring the CA199 levels. CEA, carcinoembryonic antigen.
Discussion
Lung cancer, as a common malignant tumor, has long been a major disease threatening human health. With the continuous advancement of medical technology, the treatment methods for lung cancer are also constantly being updated and improved. Unlike local treatments such as surgery and radiation therapy, systemic treatments such as chemotherapy, immunotherapy, and targeted therapy can target cancer cells that have spread to other parts of the body, improve treatment efficacy, and reduce the risk of recurrence and metastasis [12‒14]. Systemic treatment may cause some side effects, such as nausea, hair loss, and fatigue. It is necessary to promptly report to the doctor and seek corresponding relief measures.
Compared with other NSCLC patients, NSCLC patients with EGFR mutations have different prognoses and treatment options. The EGFR is an expression product of the oncogene C-Rb-1, a transmembrane protein located on the short arm of chromosome 7, with 28 exons [15, 16]. The mutations in the EGFR tyrosine kinase region mainly occur in exons 18–21, with exon 19 deletion and exon 21 L858R point mutation being the most common types of mutations, accounting for 50% and 40% of patient samples, respectively [17]. Tumors containing these two types of mutations are sensitive to EGFR TKIs.
Specifically, patients carrying rare EGFR mutations, such as G719X, S768I, and L861Q, may require special selection of EGFR-TKI. For the uncommon EGFR S768I mutation, erlotinib seems to be the best choice [18‒21]. In the past few decades, rare EGFR mutations have been more frequently associated with genomic changes, such as TP53 mutations, leading to cancer-related deaths. The third-generation EGFR TKI osimertinib is expected to change the treatment of NSCLC with uncommon EGFR mutations [22]. Patients with EGFR S768I mutations combined with TP53 gene mutations are more likely to develop resistance mechanisms, and their prognosis is worse [23]. Sebastijan Hobor’s latest research shows that lung cancer patients with EGFR and TP53 gene co-mutations are prone to genome duplication, which can lead to targeted therapy resistance [24].
Afatinib is currently the only EGFR TKI approved for patients with advanced NSCLC carrying EGFR G719X/L861Q/S768I [25‒29]. However, there are limited real-world data on the benefits and resistance mechanisms of afatinib for patients with rare EGFR mutation sites combined with TP53 mutations. To fill this gap, we reported a patient carrying EGFR S768I/V774M combined with TP53 mutation. Due to the expression level of PD-L1 immunohistochemistry in the patient: TPS around 10%, the patient received chemotherapy with 860 mg pemetrexed and 480 mg carboplatin in the early stage, as well as immunotherapy with 200 mg xindilimab. The response was good, but after six courses of chemotherapy, a follow-up CT scan showed disease progression, and the maximum diameter of the tumor was 52*38 mm. Subsequently, complete the panoramic 425 gene detection of solid tumors (tissue), and the second-generation sequencing reveals EGFR gene exon 20 missense mutations (p.S768I and p.V774M) with a mutation abundance of 48.6% and 49.7%, respectively. Meanwhile, the tumor protein TP53 (TP53) gene exon 6 missense mutation (p.Y220C) occurred with a mutation abundance of 49.2%. The patient’s treatment plan has been adjusted to chemotherapy with paclitaxel albumin 400 mg + immunotherapy with pembrolizumab 200 mg, and targeted treatment with oral afatinib. After 4 months of treatment, the patient developed severe diarrhea and headache and suspended pembrolizumab. Albumin paclitaxel 400 mg chemotherapy was continued, while afatinib 30 mg targeted therapy was adjusted. Immune checkpoint inhibitors have multiple side effects, including gastrointestinal [30], skin, liver, and other toxicity [31, 32].
Our case report indicates that targeted treatment with afatinib for EGFR S768I/V774M, TP53 mutations, and stage IVa NSCLC patients during neoadjuvant therapy resulted in good patient response and PFS of 12 months. In December 2022, the patient’s condition worsened and the head MR showed an enlarged lesion, indicating brain metastasis. The treatment was changed to targeted therapy with osimertinib, with good response and PFS of 7 months; however, the patient developed severe gastrointestinal symptoms and stopped taking the medication on their own. In November 2023, the patient switched to targeted therapy with famitinib and PFS of 3 months. After discharge, the patient had recurrent high fever and was treated with anti-infective therapy. Starting from March 2024, the patient switched to targeted therapy with sunvozertinib of PFS of 3 months. Kaibo Ding’s [33] research reported a case of rare EGFR exon 18 delE709_T710insD mutation in NSCLC, which showed significant clinical efficacy of sunvozertinib in treating EGFR rare mutation sites, with PFS reaching months. However, our patient’s condition worsened within less than 3 months after sunvozertinib targeted therapy, indicating that TP53 co-mutation accelerates the development of EGFR rare mutation combined with drug resistance. Of course, more cases are needed to verify this.
After 3 months of treatment with sunvozertinib, CT reexamination showed that the tumor significantly shrank. The level of carcinoembryonic antigen in serum significantly decreased from 7,339.3 ng/mL to 5,686.9 ng/mL (Fig. 3a), and glycoantigen 125 and glycoantigen 199 in serum were also significantly reduced, which indicates that the targeted therapy effect of sunvozertinib is significant. But in the fourth month of receiving treatment with sunitinib, the patient’s condition worsened, with a high fever and a maximum body temperature of 39°C, accompanied by sore throat, cough, sputum, chest tightness, and back pain. The blood test showed a white blood cell count of 10.72*109/L, a neutrophil count of 7.45*109/L, hemoglobin of 136 g/L, high-sensitivity C-reactive protein of 38.63 mg/L, aspartate aminotransferase of 161 U/L, total bilirubin of 25.2 μmol/L, and glutamyl transpeptidase of 1,637 U/L, indicating liver injury in the patient. The CT scan showed disease progression. The patient’s condition is critical, and the patient and their family requested discharge. The diagnosis and treatment schedule of the patient are shown in Figure 4.
In conclusion, TP53 mutations may interfere with the acceleration of EGFR S768I/V774M resistance mechanism, leading to a lack of response to targeted drugs such as famitinib and sunvozertinib, resulting in shortened PFS. However, the patient responded well to platinum-based chemotherapy, and the response to afatinib targeted therapy was good with PFS of 12 months. When brain metastasis occurred, the PFS of osimertinib reached 7 months and was discontinued due to gastrointestinal adverse reactions. In addition, this case emphasizes the importance of releasing treatment response data for rare EGFR mutation combined with TP53 mutation cancer cases to guide clinical decision-making. The authors have completed the CARE Checklist for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000543453).
Acknowledgments
H.Z. takes primary responsibility for the integrity of the review article and thanks all the authors for their contributions to this review article.
Statement of Ethics
This research protocol has been reviewed and approved by the Ethics Review Committee of the First Affiliated Hospital of Zhejiang University School of Medicine, with Approval No. IIT20241131A. Written informed consent has been obtained from the participant to release detailed information on their medical case and any accompanying images.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
This work was supported by the Natural Science Foundation of Zhejiang Province (LY22H090021).
Author Contributions
Huijuan Zhu: writing – review and editing, writing – original draft, validation, methodology, data curation, and conceptualization. Hui Tang: validation, methodology, investigation, and data curation. Huizhen Peng: validation, investigation, and data curation. Ding Wei: validation, software, methodology, investigation, formal analysis, and data curation.
Data Availability Statement
The data that support the findings of this study are not publicly available due to their containing information that could compromise the privacy of research participants but are available from the corresponding author upon reasonable request.