EGFR L858R-mutant Stage IV lung adenocarcinoma managed after gefitinib-induced lung injury

What happened, in summary

This 48-year-old man was admitted with fever and chills that did not improve after antibiotics for presumed pneumonia. CT imaging showed a right middle-lobe lung mass with hilar and mediastinal lymphadenopathy. Abdominal imaging showed abnormal changes in the left hepatic lobe and lymphadenopathy along the common hepatic artery, and PET/CT showed uptake in the lung region and vertebrae. Brain MRI did not show brain metastasis. Bronchoscopy confirmed adenocarcinoma, and he was diagnosed with Stage IV lung adenocarcinoma with liver and bone metastases. Molecular testing showed an EGFR L858R mutation. He started gefitinib 250 mg daily, and his general condition quickly improved. One month later, he developed fever and progressive shortness of breath. CT showed that the primary tumor and lymph nodes had shrunk, but new diffuse ground-glass opacities were present in both lungs. Gefitinib was stopped because it was considered the likely cause of interstitial lung disease. He received methylprednisolone 500 mg daily for 3 days, then prednisolone 30 mg daily with tapering, and his breathing gradually improved. Two months later, scans still showed shrinkage of the lung tumor and lymph nodes, but the liver tumor had regrown. He then received carboplatin, pemetrexed, and bevacizumab, which produced a good response without serious treatment-related adverse events. After the fourth course, he developed black stool and hypotension from esophageal and gastric varices. Blood transfusion and endoscopic variceal ligation controlled the bleeding, and follow-up endoscopy showed regression of the varices. The case links molecularly targeted therapy, treatment-limiting lung toxicity, chemotherapy response, and portal-hypertension-related bleeding in a single metastatic EGFR-mutant lung cancer course.