Malignant thrombosis of the superior vena cava caused by non-small-cell lung cancer treated with radiation and erlotinib: a case with complete and prolonged response over 3 years

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Open Access Full Text Article Malignant thrombosis of the superior vena cava caused by non-small-cell lung cancer treated with radiation and erlotinib: a case with complete and prolonged response over 3 years This article was published in the following Dove Press journal: OncoTargets and Therapy 28 June 2013 Number of times this article has been viewed Jianyang Wang 1 Jun Liang 1 Wenqing Wang 1 Han Ouyang 2 Luhua Wang 1 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 2Department of Diagnostic Radiology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China 1 Abstract: Most cases of superior vena cava (SVC) syndrome resulting from neoplasm, especially from lung cancer, remain a serious challenge to treat. Here, for the first time as far as we are aware, we report the case of a non-small-cell lung cancer patient with a massive SVC malignant thrombosis who was treated with thoracic irradiation and erlotinib. The treatment regimen consisted of erlotinib 150 mg/day and a total dose of 66 Gy/33 fractions delivered to the tumor, malignant thrombosis, and metastasis mediastinal lymph nodes. The malignant thrombosis responded dramatically and the combined regimen was well tolerated. After discharge, the erlotinib was prescribed as maintenance therapy. The patient was followed closely for the next 3 years. During this time, positron emission tomography/computed tomography scans and serum tumor marker screens were undertaken. By 6 months, the primary tumor showed complete response and by 9 months, the SVC thrombosis had disappeared. No sign of relapse has been found to date. Keywords: superior vena cava syndrome, radiotherapy, thoracic irradiation, neoplasm Introduction The majority of cases of superior vena cava (SVC) syndrome result from neoplasm, particularly lung cancer.1 Here, for the first time as far as we are aware, we report the case of a non-small-cell lung cancer (NSCLC) patient with massive SVC malignant thrombosis who was treated with thoracic irradiation and erlotinib, subsequently achieving complete remission of the cancer and long-term disease-free survival over 3 years. Case report Correspondence: Luhua Wang Department of Radiation Oncology, Cancer Hospital and Institute, Panjiayuan Nanli #17, Chaoyang District, Beijing 100021, People’s Republic of China Tel +86 10 87788799 Fax +86 10 67706153 Email submit your manuscript | www.dovepress.com Dovepress http://dx.doi.org/10.2147/OTT.S45660 Powered by TCPDF (www.tcpdf.org) A 61-year-old man presented to the hospital with a 3-month history of progressive edema of the head, neck, arms, and upper chest, followed by shortness of breath and distention of the jugular and chest veins. The medical history of the patient revealed 30 years of tobacco use. The whole-body positron emission tomography/computed tomography (PET/CT) scan revealed a mass (1.5 × 1.0 cm) in the upper lobe of the right lung, with a maximal standard uptake value (SUVmax) of 4.2; enlarged lymph nodes in levels 1, 2R, and 4R; and a huge 7.4 cm long mass with a SUVmax of 8.9 (Figure 1A) inside the SVC, which was confirmed by magnetic resonance imaging (Figure 1B). Core needle biopsy samples of the enlarged lymph nodes yielded NSCLC (possibly adenocarcinoma) with epidermal growth factor receptor (EGFR) protein expression. Owing to inadequate tumor sample volume, the EGFR gene was not tested OncoTargets and Therapy 2013:6 749–753 © 2013 Wang et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. 749 Dovepress OncoTargets and Therapy downloaded from https://www.dovepress.com/ by 191.143.231.110 on 18-Jun-2020 For personal use only. Wang et al Figure 1 Malignant thrombosis of the superior vena cava before treatment: (A) whole-body positron emission tomography/computed tomography scan; (B) magnetic resonance image. for somatic mutation. No evidence of distant metastasis was found and the disease was diagnosed as primary adenocarcinoma of the lung (cT1N2M0), with malignant thrombosis of the SVC. After consulting with the oncologists, the patient was treated with thoracic intensity-modulated radiation therapy and erlotinib at a dosage of 150 mg/day, in order to avoid chemotherapy which may result in nausea and vomiting, could cause the drop of thrombosis. A loop diuretic (hydrochlorothiazide 50 mg) was also used to relieve the SVC syndrome for the first week. Thoracic intensity-modulated radiation therapy was delivered to the planning target volume at a total dose of 66 Gy at 2 Gy per fraction (five times per week). The planning target volume was created by a 5 mm isotropic expansion of the clinical target volume, which encompassed the gross tumor volume and the subcarinal nodes, ipsilateral mediastinum, and ipsilateral hilum. The gross tumor volume was contoured according to the PET/CT images, which included a primary lesion in the right upper lung, metastatic mediastinal lymph nodes, and malignant thrombosis of the Figure 2 Dose distribution in the primary intensity-modulated radiation therapy. The red, olive, and grey lines represent dose distributions of 66, 30, and 20 Gy, respectively. The red, blue, and green areas represent malignant thrombosis in the superior vena cava, metastatic lymph nodes, and the planning target volume, respectively. Notes: “I” indicates Inferior, “L” Left and “A” Anterior, which represents the directions of view of the patient. 750 Powered by TCPDF (www.tcpdf.org) submit your manuscript | www.dovepress.com Dovepress OncoTargets and Therapy 2013:6 OncoTargets and Therapy downloaded from https://www.dovepress.com/ by 191.143.231.110 on 18-Jun-2020 For personal use only. Dovepress SVC (Figure 2). During weekly physical examinations of the patient, the distention of the jugular and chest veins was found to have resolved completely following radiotherapy delivered at 22 Gy, while significant tumor remission was observed after radiation treatment at 40 Gy (Figure 3). On discharge, the patient was prescribed erlotinib (150 mg/day) as maintenance therapy and monitored closely for the following 45 months with PET/CT scans and serum tumor marker (STM) screens every 3 months. At 6 months after treatment, the primary tumor was found to have completely responded and at 9 months post-treatment, the SVC thrombosis had disappeared. In addition, no signs of pulmonary interstitial abnormality were observed on PET/CT. All the STMs were controlled and the lymph nodes that had been enlarged before treatment wer (...truncated)