After that, direct sequencing of the RNA extracted from cells in pleural effusion revealed EGFR Del18 (delE709_T710insD) mutation (Fig. 5A). Although it was unknown whether this mutation was sensitive, erlotinib 150 mg was started. Serious rashes on the legs forced us to cease treatment with erlotinib, which achieved stable disease. After switching to afatinib 40 mg, substantial tumor shrinkage was noted (Fig. 5B).