What happened, in summary

A man in his 70s with kidney failure treated by peritoneal dialysis developed a persistent fever. CT showed a 5 cm mass in the lower part of the right lung and a large right pleural effusion. Testing of the fluid did not find cancer cells. The effusion was eventually linked to a small opening in the diaphragm that allowed dialysis fluid to pass into the chest.

The lung mass was diagnosed as squamous cell carcinoma. Tumor testing found an uncommon EGFR G719A mutation in exon 18. During the same period, his breathing worsened severely and imaging showed widespread changes in both lungs. These were considered clinically consistent with malignant lymphangitis, meaning cancer affecting the lung’s lymphatic channels.

His dialysis was changed from peritoneal dialysis to hemodialysis. Pleural drainage and oxygen were used to support his breathing, and a surgical shunt was placed to manage the connection across the diaphragm.

Because the tumor carried an EGFR mutation, he began afatinib at 30 mg daily. The dose was selected with attention to his dialysis and overall condition. His oxygen requirement and lung findings gradually improved. After 1 month, imaging showed that the tumor had shrunk and the severe respiratory failure had resolved. He continued afatinib for more than 3 months without a severe treatment-related adverse effect. At the latest follow-up, he remained on afatinib with improved breathing and no severe treatment toxicity.

His improvement occurred despite dialysis and a very serious initial respiratory condition, allowing oral targeted treatment to continue after the intensive supportive care.