Acute respiratory distress syndrome and severe pneumonitis after atezolizumab plus bevacizumab for hepatocellular carcinoma treatment: A case report

Su Hyeon Cho; Ga Ram You; Chan Park; Sang-Geon Cho; Jong Eun Lee; Sung Kyu Choi; Sung Bum Cho; Jae Hyun Yoon

doi:10.4251/wjgo.v15.i5.892

Acute respiratory distress syndrome and severe pneumonitis after atezolizumab plus bevacizumab for hepatocellular carcinoma treatment: A case report

World J Gastrointest Oncol. 2023 May 15;15(5):892-901. doi: 10.4251/wjgo.v15.i5.892.

Authors

Su Hyeon Cho¹, Ga Ram You², Chan Park³, Sang-Geon Cho⁴, Jong Eun Lee³, Sung Kyu Choi¹, Sung Bum Cho², Jae Hyun Yoon⁵

Affiliations

¹ Department of Gastroenterology and Hepatology, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea.
² Department of Gastroenterology and Hepatology, Hwasun Chonnam National University Hospital and Medical School, Hwasun 58128, South Korea.
³ Department of Radiology, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea.
⁴ Department of Nuclear Medicine, Chonnam National University Hospital, Hwasun 58128, South Korea.
⁵ Department of Gastroenterology and Hepatology, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea. zenmake14@gmail.com.

Abstract

Background: Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide and has a high mortality. However, the treatment options for advanced HCC are limited to tyrosine kinase inhibitors, such as sorafenib and lenvatinib. Since previous regimens have an insufficient efficacy, the combination therapy of atezolizumab and bevacizumab (Ate/Bev) has been investigated, which showed an improvement in progression-free and overall survival. However, the adverse events of this combination therapy in advanced HCC have not been established. Herein, we report a novel case of an unresectable HCC and acute respiratory distress syndrome (ARDS) after a combination therapy of Ate/Bev.

Case summary: An 82-year-old male visited our outpatient clinic for an incidentally detected liver mass. Liver magnetic resonance imaging and enhanced chest computed tomography (CT) were performed, which showed arterial hyperenhancement with washout in delayed phase suggesting HCC, and a well-defined metastatic solid nodule, respectively. F-18 fluorodeoxyglucose positron emission tomography (PET)-CT exhibited multiple hypermetabolic lesions in the iliac bone, lumbar vertebrae, and femur. Because of the high burden of the intrahepatic tumor, transarterial radioembolization was initially performed; after 37 d, a combination therapy of Ate/Bev was administered. The patient visited the emergency department three days after Ate/Bev treatment complaining of dyspnea. He was diagnosed with severe pneumonitis based on CT. Despite administering oxygen via a high-flow nasal cannula, the P/F ratio was only 74; therefore, the patient was diagnosed with ARDS based on the overall examination results. Low tidal volume with high positive end-expiratory pressure, sedative agents combined with a neuromuscular blocker, and a systemic steroid were promptly applied to manage the ARDS. However, the patient did not recover from the hypoxia and expired 31 h after being admitted.

Conclusion: Clinicians should be aware of severe pneumonitis due to the immune-related adverse events of this combination therapy, and patients should be closely monitored after therapy.

Keywords: Acute respiratory distress syndrome; Adverse events; Atezolizumab; Hepatocellular carcinoma; Pneumonitis; Systemic therapy.

Publication types

Case Reports