Case summary

57-year-old man presented with chronic progressive headache for 3 months. He initially visited hospital due to chronic headache with projectile vomiting and ataxia. He also had anorexia and lost 7 kg but he had no respiratory tract symptoms including chronic cough, dyspnea, and chest pain. His smoking history was about 10 pack-year. On his physical examination, pupils with 4 mm. in size and reactive to light, papilledema both eyes and tongue deviation to the left side were detected but others were unremarkable. His routine investigations including chest radiography were unremarkable. He was evaluated with MRI of the brain which showed multiple enhancing lesions at the left lateral ventricle, left temporal horn, 4^th ventricle, bilateral foramen of Luschka and both sides of foramen magnum with obstructive hydrocephalus. Consequently, he was diagnosed of intraventricular papilloma and underwent craniotomy with tumor removal and ventriculoperitoneal shunt. Subsequently, he received whole brain radiation therapy for 200 cGy. The pathological result from his intraventricular mass demonstrated papillary tumor with hobnail appearance and further immunohistochemistry was processed. The final result showed strongly diffuse positive AE1/AE3, EMA, CK7, TTF-1, and NapsinA while negative CK20 and Thyroglobulin. Consequently, it was compatible with metastatic adenocarcinoma, most likely from primary lung carcinoma. Further molecular testing demonstrated EGFR Exon 19 deletion mutation by PCR but no detection of ALK rearrangement. Later, he was evaluated with CT of the chest and upper abdomen which showed a 2.4x1.3 cm spiculated pulmonary mass at the apicoposterior segment of the left upper lobe and 0.8 cm pathological lymph node at AP window region. Bone metastasis at T3 vertebral bodies was also seen. Finally, he was diagnosed as adenocarcinoma of the left lung with intraventricular metastasis; stage T1cN2M1b. After completion of WBRT, his neurologic symptoms were improved and he still had no respiratory tract symptoms. His ECOG performance status was 1. Discussing treatment options, the patient and his family made a decision to enroll in the clinical trial for new EGFR TKI.