Factors Affecting Recurrence and Survival in Stage IIA Colon Cancer Patients.

INTRODUCTION: Our study delves into the intricate interplay of risk factors and the strategic selection of adjuvant therapy, scrutinizing their influence on recurrence and survival outcomes in stage IIA (T3N0M0) colon cancer patients. MATERIALS AND METHODS: The study examined the medical records of patients who underwent surgery for stage IIA colon cancer. Identification of stage IIA (pT3N0M0) colon cancer involved a comprehensive review of postoperative clinical records and histological reports. Parameters such as demographic data, tumor characteristics, microsatellite instability status, tumor locations, recurrence risk factors, preoperative carcinoembryonic antigen levels, and adjuvant treatments were systematically evaluated. RESULTS: In our study involving 220 patients, 138 were male (62.7%), with a median age of 62 years and a median body mass index of 25.1 kg/m2. In the patient group without risk factors, no statistically significant difference was detected in disease-free survival (DFS) rates between those who received treatment and those who did not (p = 0.546). DFS rates of patients with >1 risk factor were statistically significantly lower than those with a single risk factor (p = 0.017). In patients with >1 risk factor, the DFS of those who did not receive adjuvant treatment was significantly lower than those who received adjuvant treatment (p < 0.001). In the patient group with recurrence, when adjuvant treatments were considered, recurrence was significantly higher in the group receiving capecitabine (p = 0.01). CONCLUSION: The decision for adjuvant chemotherapy in stage IIA colon cancer patients involves careful consideration of various parameters and risk factors. The evolving landscape of research may refine recommendations, ensuring optimal treatment outcomes while minimizing unnecessary toxicity.

The demographic characteristics, prognosis, and relationship with cancer subtypes of hospitalized COVID-19 patients with malignancy: A single-center experience.

Undoubtedly, cancer patients have suffered the most from the COVID-19 pandemic process. However, cancer is a heterogeneous disease, and each patient has responded differently to COVID-19. We aimed to describe the clinical characteristics and outcomes of patients with cancer and COVID-19. We retrospectively reviewed 45 cancer patients hospitalized in the Cerrahpasa Medical Faculty COVID-19 department from March 23 to October 23, 2020. We analyzed the demographic characteristics, symptoms, laboratory findings, treatment, prognosis, and cancer subtypes of patients and mortality who were hospitalized for COVID-19. Between March 23 and October 23, 2020, 45 hospitalized cancer patients who had laboratory-confirmed COVID-19 infection were included, with a median age of 60 years (range: 23-92). Patients were divided into two groups a survivor and a non-survivor. Symptoms, demographic information, comorbidities, treatments for COVID-19, and laboratory findings of the two groups were evaluated separately. Two parameters were found, which showed a significant difference between non-survivors and survivors displaying a disadvantage for COPD and low platelet count (p = 0.044-0.038). The mortality rate of all patients was 66%. The presence of comorbidities such as COPD and low platelet count in cancer patients with COVID-19 infection may draw the attention of physicians.

Use of volumetric CT scanning to predict tumor staging and survival in pancreatic cancer patients that are to be administered curative resection.

BACKGROUND: This study evaluates the achievability of CT volumetry of pancreatic cancer and its correlation with pTNM stage and survival. METHODS: Tumor volume was measured from contrast enhanced CT images of 58 patients who undergo curative resection for pancreatic cancer using the Segment Editor module implemented in 3D-Slicer-a free open source software platform. Receiver operating characteristic (ROC) analysis was used to evaluate correlation between Tvol and pTNM staging. RESULTS: The preoperative images of 58 pancreatic adenocarcinoma patients were included. The mean Tvol of pancreatic cancer is an increasing trend with T stage (The mean T1vol = 1.75 cm3 , the mean T2vol = 11.43 cm3 , the mean T3vol = 14.98 cm3 , the mean T4vol = 19.6 cm3 ). There were statistical differences between volumes (p = .000). On ROC analysis, the area under the ROC curve (Az) of Tvol to differentiate T1 stage from ≥T2 stage was 0.966 (p = .000). At a cut-off value of 3.050 cm3 , sensitivity of 92.3%, and specificity of 83.3% were achieved. Az value of Tvol to differentiate ≤T2 from ≥T3 stage was 0.750 (p = .010). At a cut-off value of 10.250 cm3 , sensitivity of 72.7% and specificity of 66% were achieved. In addition Az value of Tvol to differentiate ≤T3 from ≥T4 stage was 0.652 and was not significant (p = .380). At a cut-off value of 11.2 cm3 , sensitivity of 66.7% and specificity of 63.6% were achieved. CONCLUSION: CT volumetry in pancreatic cancer is feasible with excellent reproducibility. It is one of the prognostic factors affecting survival in operated patients with pancreatic cancer.

Classical versus non-classical EGFR mutations: Erlotinib response and impact of renal insufficiency.

INTRODUCTION: Erlotinib is an effective treatment option for EGFR-mutant non-small cell lung cancer. It is important to predict patients who will respond better to erlotinib. We designed this study to investigate the effect of renal insufficiency (RI) on erlotinib treatment outcomes. METHODS: All patients receiving erlotinib were stratified into 3 groups. Group 1 consisted of non-RI subjects with classical epidermal growth factor receptor (EGFR) mutations, Group 2 consisted of those with RI (Estimated glomerular filtration rate <60 mL/min) and classical EGFR mutations, and Group 3 consisted of those with non-classical EGFR mutations. RESULTS: 82 patients were included in the study. Median progression-free survival (PFS) in patients with classical mutation was approximately 6 months shorter in those with RI, although not statistically significant. Median overall survival (OS) in Group 1, 2 and 3 was 34.1 months, 35.2 months, and 15 months, respectively and although not statistically significant, median OS was 20 months shorter in Group 3. Univariate and multivariate cox-regression analysis revealed shorter PFS and OS in males and those with ECOG ≥2 while PFS and OS were longer in those with recurrent lung tumors and generating rash during erlotinib treatment. There was no difference between RI and non-RI patients in terms of adverse events except for fatigue and appetite loss. CONCLUSIONS: This research showed OS in patients with and without RI was comparable. Although not statistically significant, PFS in patients with classical mutation was approximately 6 months shorter in those with RI patients.

Complete response after ceritinib treatment in non-small cell lung cancer in an elderly patient.

INTRODUCTION: Ceritinib is a selective second-generation ALK inhibitor that is highly sensitive to echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) molecule. CASE REPORT: In this paper, we report a 68-year-old female that was diagnosed with stage 4 ALK-positive non-small cell lung cancer (NSCLC).Management and outcome: She was treated with crizotinib first-line, cisplatin and gemcitabine as second-line. And for third-line, ceritinib was started. She had complete response over 3.5 years under ceritinib treatment. And she is still receiving ceritinib with no adverse event. DISCUSSION: Cases achieving complete response with ceritinib treatment are rare. In this paper, we aimed to emphasize the complete response in stage 4 NSCLC in an elderly patient.

Follicular lymphoma generating in a patient with non-small cell lung cancer following nivolumab discontinuation.

INTRODUCTION: Immune checkpoint inhibitors have demonstrated the benefit for many cancer types, melanoma, non-small cell lung cancer, urothelial cancer, renal cell cancer, etc. Especially in advanced non-small cell lung cancer, significant improvement in survival results has been shown. CASE REPORT: Here, we report a 66-year-old man with lung adenocarcinoma who received nivolumab for 80 cycles.Management and Outcome: Two months after discontinuing nivolumab, he developed follicular lymphoma. Pneumonitis was also accompanied, which was treated with metilprednisolon, but he died due to progressive respiratory failure. DISCUSSION: Our clinical knowledge with checkpoint inhibitors is increasing day by day, and to the best of our knowledge, this paper presents the first case in the English literature who developed follicular lymphoma after discontinuing nivolumab in non-small cell lung cancer patient.

The top 100 cited articles in lung cancer - a bibliometric analysis.

AIM OF THE STUDY: To analyze the 100 most cited lung cancer articles published in biomedical literature in the last 44 years. We pointed out developments in lung cancer and aimed to create convenient access for the researchers of this dynamic field. MATERIAL AND METHODS: We accessed the WoS database (accessed: 15.07.2019) using the keyword "lung cancer" between 1975 and 2019. The top 100 cited articles were analyzed by topic, journal, author, year, institution, level of evidence, adjusted citation index and also the correlations between citation, adjusted citation index, impact factor and length of time since publication. RESULTS: A total of 240,701 eligible articles were identified and we chose the top 100 articles cited in the field of lung cancer. The mean number of citations for these articles was 1879.82 ±1264.78. The most cited article was (times cited: 7751) a study by Lynch et al. The New England Journal of Medicine (NEJM) made the greatest contribution to the top 100 list with 32 articles, and the most cited article also originated from NEJM. The highest number of citations was seen in 2017 with 18,393 citations while the highest number of publications was seen in 2005 with 12 publications. CONCLUSIONS: Oncology is a developing field and we have seen the evolution in this area through the treatment of lung cancer in recent years. The first 100 articles in our analysis not only reflect the landmark articles with the greatest impact on lung cancer research, but also acknowledge the most productive authors and institutions that have contributed to the list with their articles.

Is the serum level of survivin, an antiapoptotic protein, a potential predictive and prognostic biomarker in metastatic pancreatic cancer?

In the present study, we aimed to assess the association between the serum survivin level and overall survival and treatment response rates in metastatic pancreatic cancer (MPC). Serum samples were prospectively collected from 41 patients with newly diagnosed MPC patients and 41 healthy individuals (control group) to assess the survivin levels. The median survivin level was 136.2 ng/mL in patients with MPC and 52 ng/mL in healthy individuals (P = .028). Patients were divided into low- and high-survivin groups according to the baseline median survivin level. Patients with a high serum survivin level compared with a low serum survivin level had shorter median progression-free survival (2.39 vs 7.06 months; P = .008, respectively) and overall survival (3.74 vs 9.52 months; P = .026, respectively). Patients with higher serum survivin levels had significantly worse response rates (P = .007). The baseline high level of serum survivin in patients with MPC may be associated with treatment resistance and poor prognosis. A confirmation will be needed for these results in future large multicenter prospective studies.

Decrease in estimated glomerular filtration rates in non-small cell lung cancer patients treated with crizotinib.

Introduction: Crizotinib is a tyrosine kinase inhibitor used in patients with non-small cell lung cancer, and there are uncertainties about its effect on kidney function. In this study, it was aimed to document the possible adverse effect of the drug on kidney functions. Materials and Methods: The estimated glomerular filtration rates (eGFRs) of the patients were calculated by creatinine-based Chronic Kidney Disease Epidemiology Collaboration and compared by months using the paired samples t-test. Kaplan-Meier survival method was used for progression-free survival and overall survival (OS) analysis. Results: Twenty-six patients who received crizotinib were included in the study, and the median progression-free survival time with crizotinib was 14.2 months and the median OS time was 27.4 months. There was a significant reduction of eGFR after the 1st month of crizotinib treatment when compared to the rate before treatment initiation (P < 0.001). The eGFR values at the end of the 1st month and the 2nd month of treatment and the 2nd and 3rd months of treatment were statistically similar (P = 0.086, P = 0.663; respectively). This decrease in eGFR values was reversible, and there was no difference detected between pretreatment and posttreatment discontinuation (P = 0.100). Conclusion: A reversible decrease in renal functions was detected in patients using crizotinib. When the literature data are examined, it is thought that the reason for this decrease may be related to the increase in renal inflammation or a pseudo decrease due to the decrease in creatinine excretion. When evaluating renal functions in these patients, using noncreatine-based (iothalamate, etc.) calculations can give more accurate results.

Real-life comparison of afatinib and erlotinib in non-small cell lung cancer with rare EGFR exon 18 and exon 20 mutations: a Turkish Oncology Group (TOG) study.

OBJECTIVES: To compare the survival of first- and second-generation tyrosine kinase inhibitors (TKIs) in patients with rare EGFR exon 18 and exon 20 mutation-positive non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: We retrospectively evaluated survival characteristics of 125 patients with EGFR exon 18 and exon 20 mutated NSCLC who received erlotinib or afatinib as first line treatment between 2012 and 2021 from 34 oncology centres. Since exon 20 insertion is associated with TKI resistance, these 18 patients were excluded from the study. RESULTS: EGFR exon 18 mutations were seen in 60%, exon 20 mutations in 16%, and complex mutations in 24% of the patients with NSCLC who were evaluated for the study. There were 75 patients in erlotinib treated arm and 50 patients in afatinib arm. Patients treated with erlotinib had progression-free survival time (PFS) of 8.0 months and PFS was 7.0 months in the afatinib arm (p = 0.869), while overall survival time (OS) was 20.0 vs 24.8 months, respectively (p = 0.190). PFS of exon 18 mutated arm was 7.0 months, exon 20 mutated arm was 4.3 months, and complex mutation positive group was 17.3 months, and this was statistically significant (p = 0.036). The longest OS was 32.5 months, seen in the complex mutations group, which was not statistically different than exon 18 and in exon 20 mutated groups (21.0 and 21.2 months, respectively) (p = 0.323). CONCLUSION: In this patient group, especially patients with complex mutations are as sensitive to EGFR TKI treatment similar to classical mutations, and in patients with rare exon 18 and exon 20 EGFR mutation both first- and second-generation EGFR-TKIs should be considered, especially as first- and second-line options.

Breast cancer to thyroid gland: An unconventional metastatic site.

Thyroid gland blood supply is rich but it is not an open area for metastasis. Only 1%-3% of the neoplastic lesions seen in the thyroid are of extrathyroidal origin. Thyroid, lung, bone, lymph node metastasis were detected at the time of diagnosis in a 78-year-old woman with metastatic breast cancer. Control imaging was performed 3 months after hormone therapy was started. All lesions were regressed except thyroid lesion and neck lymph. Tru-cut biopsy was performed to the lesion in the thyroid. The result is consistent with breast cancer metastasis. With this breast cancer metastasis to thyroid case, we want to emphasize the differential diagnosis of neoplastic lesions in the thyroid is important in those diagnosed with malignancy. If there is clinical suspicion after a nondiagnostic thyroid sampling, repeated biopsies should be performed.

A rare case of cardiac toxicity in a patient with imatinib treatment: Case report.

Imatinib, a tyrosine kinase inhibitor, primarily used to treat chronic myeloid leukemia, has shown a survival benefit in gastrointestinal stromal tumors (GISTs). The most common toxicities of imatinib include fluid retention, diarrhea, nausea, fatigue, muscle cramps, abdominal pain, and rash. Imatinib-related cardiotoxicity is a rare condition, and its clinical severity varies between asymptomatic mild ventricular dysfunction and severe congestive heart failure (CHF). We report the case of a 64-year-old woman with a history of GIST who presented to our clinic with rapidly progressive dyspnea. After 8 weeks of imatinib treatment, the patient developed CHF. Echocardiography showed decreased ejection fraction. Imatinib was stopped and diuretic therapy was started. Two weeks later, she died. Cardiac shock was her cause of death.

A single center's experience of the extrapulmonary neuroendocrine carcinomas.

Objective: Extrapulmonary neuroendocrine carcinoma (EP-NEC) is a rare tumor type, and a standard therapy for EP-NEC has not yet been established. The purpose of this research was to explore the overall survival (OS) and therapeutic effects of platinum-etoposide combination therapy in EP-NEC. Methods: This retrospective study was conducted based on the medical records from January 2010 to March 2020. Eligible patients had been pathologically diagnosed with EP-NEC. Results: Forty-seven patients were included in the study. About 72.3% (n=34) of the patients were diagnosed with metastatic disease at the first diagnosis. The most common primary tumor site was the stomach. The median progression-free survival (PFS) of the patient group, who received the combination of platinum/etoposide, was 5.83 months (95% CI 4.46-7.20), whereas the median OS of the patients, who were found to have metastatic disease at the first diagnosis, was 13.6 months (95% CI 9.01-18.18). There was no difference in PFS and OS between patients with and without liver metastasis. Conclusion: The outcome of advanced EP-NECs with platinum/etoposide chemotherapy remains poor. Obviously, there is a need for new, more effective treatment options.

The Relationship Between Symptom Severity and Caregiver Burden in Cancer Patients Under Palliative Care: A Cross-Sectional Study.

BACKGROUND: Hospitalization is a stressful experience both for primary caregivers (PCs) and cancer patients alike. Although there is significant evidence that PCs of cancer patients can experience significant caregiver burden (CB), less is known about the relationships between PCs and patient symptom severity that influence CB. Methods: In this cross-sectional study, measures of the symptom severity were obtained from cancer patients. The PCs were assessed for CB. Associations between patients' symptoms and demographic characteristics and CB were investigated using multivariate analyses. Results: A total of 98 participants (patient-caregiver dyads) filled the questionnaires. According to the Zarit Burden Interview results, 65.3% of PCs had a high CB. Pain, tiredness, nausea, depression, drowsiness, well-being, and dyspnea had significantly higher mean values in those with high CB (p < .05). Financial difficulties, first-degree relationships with the patient, higher anxiety levels, and more pronounced tiredness appear to be the variables most predictive with high CB. Conclusion: In conclusion, the present study showed CB of PCs among a group of hospitalized incurable cancer patients. PCs of more symptomatic cancer patients had a higher CB, according to our findings. This emphasized the significance of palliative care. Appropriate guidance should be provided for the psychostress caused by the CB.

Sarcopenia assessment by new EWGSOP2 criteria for predicting chemotherapy dose-limiting toxicity in patients with gastrointestinal tract tumors.

INTRODUCTION: In 2019, The EWGSOP2 group made updates on the definition and diagnosis of sarcopenia. The aim of this study is to determine the possible risk factors for chemotherapy dose-limiting toxicity (DLT). METHODS: Newly diagnosed gastrointestinal (GI) cancer patients were included in this prospective observational study. Chemotherapy DLTs were recorded in patients receiving platinum-based therapy. The patients were divided into two groups according to the current sarcopenia criteria. RESULTS: 75 patients were included in the final analysis. Chemotherapy DLT occurred in 52% (n = 39) of all patients who received platinum-based chemotherapy. DLT rates were 78.9% and 42.9% in sarcopenic and non-sarcopenic patients, respectively (p = 0.007). According to the results of the multivariate analysis, the only sarcopenia was found as a statistically significant risk factor for DLT. CONCLUSION: Assessment of sarcopenia evaluated with the current EWGSOP2 diagnostic criteria is useful in predicting chemotherapy DLT development in patients with a diagnosis of GI cancer. In the future, current EWGSOP2 recommendations should be considered while designing a study investigating the correlation between sarcopenia and chemotoxicity.

Efficacy and safety of folfiri plus aflibercept in second-line treatment of metastatic colorectal cancer: Real-life data from Turkish oncology group.

Aims: The addition of aflibercept to the fluorouracil and irinotecan (FOLFIRI) regimen significantly improved clinical outcomes in patients with metastatic colorectal cancer (CRC) previously treated with oxaliplatin. We aimed to investigate the efficacy and safety of second-line FOLFIRI and aflibercept combination in patients with metastatic CRC in real-life experience. Materials and Methods: Four hundred and thirty-three patients who treated with FOLFIRI and aflibercept in the second-line were included in the study. The clinical and pathological features of the patients were recorded retrospectively. Survival (overall and progression-free survival [PFS]), response rates, and safety data were analyzed. Results: The median age was 61. Majority of patients (87.5%) received first-line bevacizumab and 10.1% of patients received anti-epidermal growth factor receptor agents. About 80% of patients had KRAS, 18.6% of patients had NRAS, and 6.4% of patients had BRAF mutations. The median OS was 11.6 months (95% confidence interval [CI], 10.6-12.6) and the median PFS was 6 months (95% CI, 5.5-6.5). About 4.6% of patients had complete response and 30.6% of patients had partial response as best tumor response. Grade 1-2 toxicities were seen in 33.4% of patients, while grade 3-4 toxicities were recorded in 27% of patients. Eight patients (2%) died due to treatment toxicity. Conclusions: Overall and PFS were similar in routine clinical practice compared to phase III pivotal VELOUR trial. However, response rates were found to be higher. It was observed that there were fewer adverse events compared to the VELOUR trial.

Facial cutaneous metastasis of rectal adenocarcinoma.

Skin metastasis caused by carcinomas is associated with poor prognosis and is a rare and late clinical finding. Skin metastases occur in only 4-6.5% of Stage IV colorectal cancer. We present an unusual case of Stage IV unresectable rectal adenocarcinoma metastasized to the head and face. One and a half years after diagnosis, new skin lesions developed on his face. Biopsy showed mucinous adenocarcinoma consistent with rectal malignancy. Moreover, he died 3 months after the diagnosis of cutaneous metastasis. This case emphasizes the importance of the effect of skin lesions on prognosis in patients with a history of malignancy.

The relationship between eGFR and capecitabine efficacy/toxicity in metastatic breast cancer.

The objective of this study was to evaluate the efficacy and toxicity of capecitabine in metastatic breast cancer (mBC) according to the estimated glomerular filtration rate (eGFR). A total of 135 patients included in the final analysis were stratified into 3 categories according to baseline eGFR, i.e., eGFR <60 mL/min/1.73 m2 (Group 1), eGFR 60-90 mL/min/1.73 m2 (Group 2) and eGFR >90 mL/min/1.73 m2 (Group 3). If a patient developed a level of toxicity that would lead to capecitabine dose reduction, this was recognized as dose-limiting toxicity (DLT). The dose was reduced due to toxicity in 95 cycles. A total of 95 DLTs were seen in 76 (56.2%) of the 135 patients. When 76 patients with DLT were evaluated according to eGFR, DLT was observed in 93.3% of those in Group 1, 72.5% of those in Group 2 and 41.3% of those in Group 3 (p < 0.001). The median time to progression (TTP) of all patients was 7.4 months. No significant difference in TTP was observed in patients stratified into 3 groups according to eGFR. When the patients were divided into two groups as DLT and without DLT, the median TTP was 8.68 months (95% CI, 7.53-9.81 months) in those with toxicity and 6.23 months (95% CI, 4.04-8.43 months) in those without toxicity (log-rank p = 0.004). We found a significant relationship between low eGFR and increased risk of DLT. Having a DLT was associated with a longer TTP. It indicates the need for more data/larger study investigating these discrepancies.

Immune-related adverse events associated with immune checkpoint inhibitors in patients with cancer.

INTRODUCTION: With the widespread use of immune checkpoint inhibitors (ICIs), we are facing challenges in the management of immune-related adverse events (irAEs). We aimed to characterize the spectrum of toxicity, management, and outcomes for irAEs. METHODS: Patients who were treated with at least one ICI in clinical trials, expanded access programs, or routine clinical practice were included. Clinical and laboratory parameters were collected retrospectively to determine the incidence of irAEs, methods of management, and treatment outcomes. RESULTS: A total of 255 patients were screened retrospectively. Of these, 71 (27.8%) patients developed irAEs. More than 2 different types of irAEs were detected in 16 (6.2%) out of 255 patients. A total of 3177 doses were given to 255 patients. In 93 (2.9%) of the 3177 doses, 1 episode of irAEs was experienced. A total of 22 out of 93 (23.7%) episodes were reported as grade 1, 49 (52.7%) as grade 2, 19 (20.4%) as grade 3, and 3 (3.2%) as grade 4. The most frequently seen irAEs were pneumonitis, hepatitis, and hypothyroidism. With regard to treatment, 39 out of 93 episodes (42%) of any grade irAEs occurred after anti-programmed cell death-1 therapy, 47 (50.5%) occurred following administration of anti-programmed death-ligand 1, and 7 (7.5%) occurred after combination treatments. CONCLUSION: With the increased use of immunotherapeutic agents, increased awareness and early recognition are required for effective management of irAEs. Our experience as a single institution might be of use for health care providers in oncology.

Real-life comparison of the afatinib and first-generation tyrosine kinase inhibitors in nonsmall cell lung cancer harboring EGFR exon 19 deletion: a Turk Oncology Group (TOG) study.

BACKGROUND: The new second-generation tyrosine kinase inhibitors (TKIs) have superior survival outcome and worse toxicity profile when compared with first-generation TKIs according to the results of clinical trials. However, there are limited studies that investigate the efficacy and safety of the new generation TKIs in real-world patients. Thus, we aimed to compare the efficacy and safety of the afatinib, an irreversible inhibitor of ErbB family receptor, and first-generation TKIs in real-world patients. MATERIALS AND METHODS: We included advanced nonsmall cell lung cancer (NSCLC) patients who had EGFR exon 19del mutation and treated with afatinib or first-generation TKIs as upfront treatment between 2016 and 2020. All patient's information was collected retrospectively. The study cohort was divided as afatinib arm and erlotinib/gefitinib arm. RESULTS: A total of 283 patients at the 24 oncology centers were included. The 89 and 193 of whom were treated with afatinib and erlotinib/gefitinib, respectively. After 12.9 months (mo) of follow-up, the median PFS was statistically longer in the afatinib arm than erlotinib/gefitinib arm (19.3 mo vs. 11.9 mo, p: 0.046) and the survival advantage was more profound in younger patients (< 65 years). The 24-mo overall survival rate was 76.1% and 49.5% in the afatinib arm and erlotinib/gefitinib arm, respectively. Although all-grade adverse event (AE) rates were similar between the two arms, grade 3-4 AE rates were higher in the afatinib arm (30.7% vs. 15.2%; p: 0.004). DISCUSSION: In our real-world study, afatinib has superior survival outcomes despite worse toxicity profile as inconsistent with clinical study results and it is the good upfront treatment option for younger patients and elderly patients who have good performance status.