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Cystic Brain Metastases in NSCLC Harboring the EML4-ALK Translocation after Treatment with Crizotinib.

1116 Journal of Thoracic Oncology ® • Volume 10, Number 7, July 2015 CASE OF THE MONTH SUBMISSION A 39-year-old woman nonsmoker presented in August 2007 with chest wall discomfort. Computed tomography (CT) revealed right upper lobe parenchymal and pleural abnormalities as well as mediastianal lymphadenopathy. Bronchoscopy and mediastinoscopy yielded a diagnosis of adenocarcinoma of the lung. No mutations in KRAS or epidermal growth factor receptor (EGFR) were identified. She received four cycles of carboplatin, paclitaxel, and bevacizumab followed by maintenance bevacizumab and erlotinib. Her tissue was reanalyzed and an anaplastic lymphoma kinase (ALK) rearrangement was detected. After disease progression in March 2011, she began crizotinib 250 mg orally twice daily on a phase II clinical trial (PROFILE 1005), ultimately achieving a complete remission. Initial magnetic resonance imaging (MRI) imaging of the brain was negative. In July 2011, she developed pupil asymmetry. MRI of the brain revealed multiple, bilateral, cystic lesions without pathological enhancement. Lumbar puncture was unremarkable. Crizotinib was continued. She received Cyberknife therapy to a lesion in the thalamus and the other lesions were observed. In September 2013, MRI of the brain demonstrated progression in size and number of the parenchymal cystic brain lesions (Fig. 1A, B). A CT scan of the chest and abdomen done at that time demonstrated disease stability. She underwent image-guided frontal craniotomy with biopsy of two cystic lesions. Pathology confirmed metastatic lung adenocarcinoma. The patient declined whole brain radiation therapy and began treatment with ceritinib (LDK387) in January 2014. An MRI of the brain performed in September 2014 demonstrated reduction of the previously noted brain metastases (Fig. 2). A chest-CT scan demonstrated continued stability of her systemic disease at that time.