Afatinib helped overcome subsequent resistance to osimertinib in a patient with NSCLC having leptomeningeal metastasis baring acquired EGFR L718Q mutation: a case report

BMC Cancer. 2019 Jul 17;19(1):702. doi: 10.1186/s12885-019-5915-7.


Background: The epidermal growth factor receptor (EGFR)-mutated advanced non-small-cell lung cancer has been successfully treated with tyrosine kinase inhibitors (TKIs). Acquired resistance becomes a tough issue when patients fail to respond to the third-generation TKI osimertinib. This study aimed to report a case baring acquired EGFR L858R/L718Q mutation in the central nervous system induced by osimertinib, which was successfully overcome using afatinib.

Case presentation: A 65-year-old female patient was diagnosed with stage IV non-small-cell lung adenocarcinoma with synchronic brain metastasis in February 2015. Before and during treatment, 416 tumor-related genes were monitored dynamically by liquid biopsies using next-generation sequencing, and the treatment strategy was decided according to the gene status. At baseline, an EGFR L858R mutation in exon 21 was detected, so treatment with icotinib was started. After 8 months, she experienced disease progression with leptomeningeal metastasis and switched to osimertinib based on an acquired EGFR T790 M mutation. After 9 months, her disease progressed and an EGFR L718Q mutation was found in the cerebrospinal fluid. The patient was then challenged with afatinib, and her disease was under control for 4 months. In January 2017, the patient passed away, with an overall survival time of 23 months, 15 months after leptomeningeal metastasis.

Conclusion: The acquired EGFR L718Q mutation in the cerebrospinal fluid resulted in subsequent resistance to osimertinib and could be partly overcome using afatinib, indicating a promising treatment option in the clinic.

Keywords: Afatinib; EGFR; L718Q; Leptomeningeal metastasis; NSCLC.

Publication types

  • Case Reports

MeSH terms

  • Acrylamides / administration & dosage
  • Acrylamides / adverse effects*
  • Acrylamides / therapeutic use
  • Afatinib / administration & dosage
  • Afatinib / therapeutic use*
  • Aged
  • Aniline Compounds / administration & dosage
  • Aniline Compounds / adverse effects*
  • Aniline Compounds / therapeutic use
  • Brain Neoplasms / secondary
  • Carcinoma, Non-Small-Cell Lung / drug therapy*
  • Carcinoma, Non-Small-Cell Lung / genetics
  • Crown Ethers / administration & dosage
  • Crown Ethers / adverse effects
  • Disease Progression
  • Drug Resistance, Neoplasm / drug effects*
  • ErbB Receptors / cerebrospinal fluid
  • ErbB Receptors / genetics
  • Fatal Outcome
  • Female
  • Follow-Up Studies
  • Humans
  • Lung Neoplasms / drug therapy*
  • Lung Neoplasms / genetics
  • Meningeal Carcinomatosis / genetics
  • Meningeal Carcinomatosis / secondary*
  • Mutation*
  • Protein Kinase Inhibitors / administration & dosage
  • Protein Kinase Inhibitors / therapeutic use*
  • Quinazolines / administration & dosage
  • Quinazolines / adverse effects


  • Acrylamides
  • Aniline Compounds
  • Crown Ethers
  • Protein Kinase Inhibitors
  • Quinazolines
  • osimertinib
  • Afatinib
  • icotinib
  • EGFR protein, human
  • ErbB Receptors