www.ijmio.com 22 As the survival in these patients increases, the scope for metastasis to another organ also increases. [10] Most ominous metastasis among these is to the brain, which occur in more than 25% of patients at some point during their disease course. [11] These patients have a poor prognosis with a median survival of only 1 month from diagnosis if untreated, 2 months with glucocorticoid therapy, and 2–5 months with whole- brain radiation therapy. [11-17] Afatinib appears to penetrate into the central nervous system (CNS) with concentrations high enough to have a clinical effect on CNS metastases. Afatinib may, therefore, be an effective treatment for heavily pretreated patients with EGFR-mutated or EGFR-TKI-sensitive NSCLC and CNS metastasis. [14] Case Report A 70-year-old male was diagnosed with adenocarcinoma right lung with clinical staging of cT 2 N 0 M 0 in 2012. Lower lobectomy was performed on 25/04/2012 with Hilar and mediastinal lymph nodal dissection. Patient’s pathological staging was pT 2 N 1 M 0 . Thereafter, the patient received adjuvant chemotherapy with 4 cycles of vinorelbine and cisplatin followed by image-guided radiation therapy that was completed in November 2012. In January 2014, the patient had back pain for which imaging was done which revealed L3 vertebral metastasis with a soft tissue component. Biopsy of soft tissue Response to afatinib, after geftinib and erlotinib, in a patient with advanced adenocarcinoma of lung with brain metastasis: A case report Prashant Mehta 1 , Pranjit Santonu Bhajoni 2 , Swati Pabbi Mehta 3 1 Department of Medical Oncology/Hematology/BMT, Asian Institute of Medical Sciences, Faridabad, Haryana, 2 Department of Pharmacology, PGIMER, Dr. Ram Manohar Lohia Hospital, New Delhi, 3 Department of Pathology, Sardar Patel Medical College, Bikaner, Rajasthan, India Correspondence to: Prashant Mehta, Asian Institute of Medical Sciences, Faridabad, Haryana, India. E-mail: prashant.mehta@aimsindia.co.in ABSTRACT Non-small-cell lung cancer (NSCLC) accounts for 80–85% of all lung cancer cases. The majority of patients present with advanced disease. Adenocarcinoma of the lung forms one of the major histopathological subtypes of metastatic NSCLC. A 70-year-old male was diagnosed with adenocarcinoma right lung with clinical staging of cT 2 N 0 M 0 in 2012. Patient was treated with adjuvant chemotherapy with 4 cycles of vinorelbine and cisplatin followed by image guided radiation therapy that was completed in November 2012. The patient was started on geftinib in Jan 2014 till January 2015 due to recurrence and progression and was subsequently switched to erlotinib as the geftinib was becoming ineffective. However, the patient developed toxicity leading to diarrhea, and the patient had to discontinue erlotinib. In view of poor general condition of the patient (ECOG performance status 4), and progression post geftinib and erlotinib he was deemed unft for chemotherapy and it was decided to start the patient on afatinib 40 mg once a day in July 2015, to which the patient responded. The patient showed signifcant improvement on afatinib. The response though partial and incomplete was substantial and further improvement was very much expected unfortunately the patient succumbed to a lower respiratory tract infection in November 2015. Key words: Adenocarcinoma lung, Afatinib, Afatinib after geftinib and erlotinib, Brain metastasis, Erlotinib, Geftinib Introduction Non-small-cell lung cancer (NSCLC) accounts for 80–85% of all lung cancer cases. The majority of patients present with advanced disease. Adenocarcinoma of the lung forms one of the major histopathological subtypes of metastatic NSCLC. [1] Adenocarcinoma cases have been increasingly reported these days possibly due to the shift to low-tar flter cigarettes, which are inhaled more deeply into the periphery of the lung. The pathogenesis of adenocarcinoma, like many other cancers, involves genetic mutations which drive the cells to become cancerous. [2] Driver mutations in the epidermal growth factor receptor (EGFR) gene are found in a subset of lung adenocarcinomas. [3] In these cancers tumor, cell survival is exquisitely dependent on EGFR pathway signaling. [4] This leaves the cancers uniquely susceptible to selective oral EGFR tyrosine kinase inhibitors (TKIs). [4] Randomized phase III clinical trials have demonstrated that these drugs have already shown surprisingly high response rates, significantly longer progression-free survival (PFS) as well as dramatic tumor shrinkage as compared to chemotherapy. [5-9] The second-generation EGFR- TKI, Afatinib has also shown signifcantly improved overall survival in patients with advanced adenocarcinoma of the lung as compared to chemotherapy, which the frst generation EGFR- TKIs have consistently failed to demonstrate. [3,7-9] Case Report Copyright: © the author(s), publisher and licensee Medip Academy. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 License, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. DOI: 10.18203/issn.2456-3994.IntJMolImmunoOncol20170056