Clinical challenges in managing brain metastatic lung adenocarcinoma without molecular testing and radiotherapy

Abstract

Stage IV lung adenocarcinoma with brain metastases is a terminal condition with high mortality that requires multimodal management, including molecular testing for genetic mutation detection, targeted therapy, chemotherapy, and radiotherapy. Molecular examinations such as EGFR, ALK, ROS1 mutations, and PD-L1 expression are currently considered the gold standard, as they allow the administration of more effective targeted therapy compared to conventional chemotherapy, while brain radiotherapy, either whole brain radiotherapy or stereotactic radiosurgery, plays an important role in controlling intracranial metastases. However, limited facilities in regional areas often hinder the implementation of standard therapy. We report a 66-year-old female with sudden decreased consciousness who was diagnosed with brain metastatic lung adenocarcinoma based on histopathological examination and multislice computed tomography (MSCT) of the thorax and head. Due to limited facilities, the patient could not undergo molecular testing or radiotherapy, so management was limited to systemic weekly paclitaxel chemotherapy for six cycles. In the second week of the first cycle, the patient showed clinical improvement, with improved consciousness and stabilization of neurological symptoms. This report illustrates that although paclitaxel is not the optimal therapy, this regimen can still provide a partial response in patients with limited access, especially in elderly patients with low performance status. Clinical studies show that weekly paclitaxel provides a therapeutic response of 30–50% with tolerable toxicity, although survival rates for patients with brain metastases without targeted therapy and radiotherapy remain low. This case emphasizes the need to develop access to molecular testing and radiotherapy services in regional healthcare facilities as a strategy to improve the quality of management for brain metastatic lung adenocarcinoma, so that patient prognosis can be improved and quality of life maintained even in terminal conditions.

Adenokarsinoma paru stadium IV dengan metastasis otak merupakan salah satu kondisi terminal dengan angka mortalitas tinggi yang memerlukan tata laksana multimodal, meliputi pemeriksaan molekuler untuk deteksi mutasi genetik, terapi target, kemoterapi, serta radioterapi. Pemeriksaan molekuler seperti mutasi EGFR, ALK, ROS1, dan ekspresi PD-L1 saat ini menjadi standar emas karena memungkinkan pemberian terapi target yang lebih efektif dibandingkan kemoterapi konvensional, sementara radioterapi otak, baik whole brain radiotherapy maupun stereotactic radiosurgery, berperan penting dalam mengendalikan metastasis intrakranial. Namun, keterbatasan fasilitas di daerah seringkali menghambat implementasi terapi standar. Kami melaporkan seorang perempuan berusia 66 tahun dengan penurunan kesadaran mendadak yang didiagnosis sebagai adenokarsinoma paru metastasis otak berdasarkan pemeriksaan histopatologi dan multislice computed tomography (MSCT) toraks serta kepala. Karena keterbatasan fasilitas, pasien tidak dapat menjalani pemeriksaan molekuler maupun radioterapi, sehingga tata laksana terbatas pada pemberian kemoterapi sistemik paklitaksel mingguan sebanyak enam siklus. Pada minggu kedua siklus pertama, pasien menunjukkan perbaikan klinis berupa kesadaran yang membaik dan stabilisasi gejala neurologis. Laporan ini menggambarkan bahwa walaupun paklitaksel bukan terapi optimal, regimen ini tetap dapat memberikan respons parsial pada pasien dengan keterbatasan akses, terutama pada pasien usia lanjut dengan status performa rendah. Studi klinis menunjukkan bahwa paklitaksel mingguan memberikan respons terapi sebesar 30–50% dengan toksisitas yang dapat ditoleransi, meskipun angka kelangsungan hidup pasien metastasis otak tanpa terapi target dan radioterapi tetap rendah. Kasus ini menegaskan perlunya pengembangan akses pemeriksaan molekuler dan layanan radioterapi di fasilitas kesehatan daerah sebagai strategi peningkatan kualitas tata laksana adenokarsinoma paru metastasis otak, sehingga prognosis pasien dapat diperbaiki dan kualitas hidup tetap terjaga meskipun dalam kondisi terminal.