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BMJ Case Rep
2021 Apr 27;144:. doi: 10.1136/bcr-2020-240295.
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EML4-ALK positive lung adenocarcinoma with skeletal muscle metastasis in the right calf which was treatable with lorlatinib after resistance to treatment with alectinib.
Matsuda H
,
Hara M
,
Iwakami SI
,
Takahashi K
.
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This report concerns a patient with skeletal muscle metastases due to lung adenocarcinoma harbouring an echinoderm microtubule-associated protein-like-4 (EML4)-anaplastic lymphoma kinase (ALK) rearrangement, who was successfully treated with lorlatinib after resistance to alectinib. A right lower lobectomy based on a diagnosis of lung adenocarcinoma was performed on a 77-year-old Japanese woman. After 7 months of surgical resection, a mass in the right calf was observed. A fine-needle aspiration biopsy from the mass was performed and the mass was diagnosed as metastatic adenocarcinoma harbouring EML4-ALK rearrangement. Alectinib was administered for 10 months. Then, administration of lorlatinib, an ALK tyrosine kinase inhibitor classified as third generation, was initiated after resistance to treatment with alectinib. After starting treatment with lorlatinib, the gastrocnemius tumour diminished and has maintained a stable condition. Our case suggests that EML4-ALK positive lung adenocarcinoma is treatable with lorlatinib after resistance to treatment with alectinib.
Figure 1. Chest X-ray showing a 39 mm solid mass in the right middle lung field (A). CT of the chest showing a 34×26 mm solid mass in the S6 of the right lung (B).
Figure 2. Positron emission tomography CT showing abnormal uptakes in the right lung hilar lymph node (A), the right popliteal lymph node and the right gastrocnemius (B). A contrast-enhanced MRI of the right leg showing a tumour in the gastrocnemius with heterogeneously high contrast on the T2 emphasised image (C) and the gadolinium enhanced the peripheral of the tumour (D).
Figure 3. Histopathology slides obtained from the gastrocnemius tumour and the lung. H&E stain exam (×20) from the gastrocnemius tumour (A) and the lung (C). Immunohistochemistry studies (×20) from the gastrocnemius tumour revealing diffused expression of cytokeratin 7 (B). Both H&E stains from the gastrocnemius tumour (A) and the lung (C) revealing tumour cells with acinar pattern.
Figure 4. Enhanced CT showing the skeletal muscle metastases in the right leg before (A) and after (B) 2 months of taking lorlatinib. The tumour exhibited a response with lorlatinib.
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