背景:肝细胞癌(HCC)是全球最常见的癌症之一,死亡率很高。然而,晚期肝癌的治疗方案仅限于酪氨酸激酶抑制剂,如索拉非尼和乐伐替尼。由于以前的方案疗效不足,阿妥珠单抗和贝伐单抗(Ate/Bev)的联合治疗已经进行了研究,显示无进展生存期和总生存期均有改善.然而,这种联合治疗在晚期HCC中的不良事件尚未确定.在这里,我们报告了一个新的病例,在Ate/Bev的联合治疗后,不可切除的HCC和急性呼吸窘迫综合征(ARDS)。
方法:一名82岁男性因偶然发现的肝脏肿块到我们的门诊就诊。进行肝脏磁共振成像和增强胸部计算机断层扫描(CT),这表明动脉过度增强与冲洗在延迟阶段提示肝癌,一个明确的转移性实性结节,分别。F-18氟代脱氧葡萄糖正电子发射断层扫描(PET)-CT显示在髂骨中多个高代谢病变,腰椎,和股骨。由于肝内肿瘤的高负担,最初进行经动脉放疗栓塞;37d后,采用Ate/Bev联合治疗。患者在Ate/Bev治疗后三天就诊于急诊科,抱怨呼吸困难。根据CT诊断为严重肺炎。尽管通过高流量鼻插管给氧,市盈率仅为74;因此,根据总体检查结果,患者被诊断为ARDS.低潮气量高呼气末正压,镇静剂联合神经肌肉阻滞剂,并及时应用全身性类固醇治疗ARDS.然而,患者没有从缺氧中恢复,并在入院31小时后死亡。
结论:临床医生应该意识到这种联合治疗的免疫相关不良事件导致的严重肺炎。治疗后应密切监测患者。
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.
METHODS: 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.
CONCLUSIONS: 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.