CASE REPORT SPRINGER LUNG CANCER INTERNATIONAL PRECEPTORSHIP VIENNA Stefan Jungbauer, Universital hospital of Erlangen, Department of internal medicine 1 01

Anamnesis 45year old female patient presented to an externe clinic with dyspnoe for 5 days thoracic pain on the right side for four weeks no haemoptysis risk factor: no smoking no weight loss, fever or night sweat medication: ibuprofen as needed, Candesartan 8mg 1/

physical examination well-developed, well-nourished woman chest: decreased breath sound on the right heart: notable for a normal S1, S2 without frequent extrasystole and no rubs, murmurs or gallops. abdomen: soft, no pain, normoactive bowel sounds in all 4 quadrants. extremities: no edema. neurologic exam: Cranial nerves II through XII are grossly intact. Strength is 5 out of 5 throughout with 2+ reflexes. Sensation to fine touch is intact throughout. The patient is alert and oriented x 3. 03

Differential diagnosis Respiratory infection with pleuritis Pulmonary embolism Cardiac insufficiency Cardiac infarction Trauma Etc. 04

Lab –Blood count was normal –Electrolytes, kreatinine, liver function tests and CRP were normal –Troponine was normal –Pathologic LDH 410+ (<214) D-dimere 1,39+ (<0,5µg/ml)

Further tests –ECG: was normal –Chest X-ray: huge pleural effusion on the right side –Echocardiography: sinus rhythm, no abnormality of repolarisation, indifferent type, PQ<0,2sec, QRS<0,1sec –Cardiac ultrasound: normal right and left ventricular function, ejection fraction 60%, valve function was normal, no pericardial effusion NEXT step?

CT scan Date: Subject: Content:

Thoracentesis pleural effusion on the right side  thoracentesis was performed LDH and protein were elevated  exudate pathology: TTF1 positive adenocarcinoma 08

Bronchoscopy Endobronchial ultrasound with transbronchial aspiration of lymph nodes postion 12R and 7 No endobronchial tumor lesions

Pathology Strong positivity for CK7 and TTF1; negativitaty for CK5, synaptophysin  primary adenocarcinoma of the lung EGFR-mutation analysis of the exons 18-21: –Exon 19 deletion was found No EML-4ALK translocation

P Further medical history Staging: cT3N2M1a (PLEUR) Afatinib-therapy was started with 40mg per day (19/02/2014) Pleurodesis with talc was performed 2/2014 Staging was performed by CT scan 08/2015: progress with pleural effusion occurred Higher dosage of Afatinib (50mg per day) was tried because of very good therapy tolerance and no side effects under 40mg 09/2015: Systemic therapy with cisplatin 75mg/m 2 and pemetrexed 500mg/m 2 was started (6 bouts of chemotherapy) Maintenance therapy with pemetrexed 500mg/m 2 since 1/2016 liquid biopsy for T790M mutation was negative