Gefitinib-induced lung injury successfully treated with high-dose corticosteroids

Valsartan prevents gefitinib-induced lung inflammation, oxidative stress, and alteration of plasma metabolites in rats

Gefitinib (GEF) is an inhibitor of the epidermal growth factor receptor, linked to higher risk of severe/fatal interstitial lung disease (ILD). This study was performed to determine the protective roles of an angiotensin-II type-1 receptor (AT1R) "valsartan (VAL)" in prevention of lung inflammation, oxidative stress and metabolites alteration induced by GEF. Four groups of male Wistar albino rats were received vehicle, VAL (30 mg/kg), GEF (30 mg/kg), or both for four weeks. Blood samples and lungs were harvested for plasma metabolites and histological analysis, respectively, and evaluation of inflammation and oxidative stress. GEF monotherapy showed a dense inflammation in lungs, and significantly increased tumor necrosis factor-α (P = 0.0349), interleukin-6 (P < 0.0001), chemokine ligand-3 (P = 0.0420), and interleukin-1β (P = 0.0377). GEF increased oxidative stress markers including glutathione, malondialdehyde, and catalase levels. Also, several plasma metabolites including butanoic acid, N-methylphenylethanolamine, oxalic acid, l-alanine, phosphoric acid, l-theorinine, pyroglutamic acid, and 2-bromosebacic acid were changed by GEF. The combination of VAL plus GEF reduced the inflammation and oxidative stress mediated by GEF monotherapy. In addition, the combination treatment returned plasma metabolites to the normal levels compared to GEF monotherapy. These findings revealed that VAL has a possible pulmonary protective role against pulmonary toxicity of GEF, which may lead to novel approaches for management of GEF-induced ILD.

Pulmonary toxicity in driver gene positive non-small cell lung cancer therapy

Molecular targeted therapy significantly improved the therapeutic efficacy in non-small cell lung cancer (NSCLC) patients with driver gene mutations but also with new toxicity profiles. Although most patients treated with these drugs developed relatively controllable toxicity, significant pulmonary toxicity events, including interstitial lung disease, occurred in a small proportion of patients and can lead to discontinuation or even be life-threatening. Pulmonary toxicity associated with these anti-tumor drugs is a problem that cannot be ignored in clinical practice. The prompt diagnosis of drug-related lung injury and the consequent differential diagnosis with other forms of pulmonary disease are critical in the management of pulmonary toxicity. Current knowledge of the pathophysiology and management of pulmonary toxicity associated with these targeted drugs is limited, and participants should be able to identify and respond to the development of drug-induced pulmonary toxicity. This review offers information about the potential pathogenesis, risk factors and management for the development of these events based on the available literature. This review focused on pulmonary toxicities in driver gene-positive NSCLC therapy by describing the related adverse events to promote the awareness and management of this important toxicity related to antitumor-targeted therapy.

Pulmonary Toxicities of Gefitinib in Patients With Advanced Non-Small-Cell Lung Cancer: A Meta-Analysis of Randomized Controlled Trials

Gefitinib is a selective tyrosine kinase inhibitor of the epidermal growth factor receptor (EGFR) used to treat adults with EGFR mutation-positive non-small-cell lung cancer (NSCLC). Clinical benefits of gefitinib administration in NSCLC patients have been observed in clinical practice, but the extent of the pulmonary toxicity of gefitinib in patients with advanced NSCLC remains unclear. The aim of this systematic review was to evaluate the overall incidence and risk of gefitinib-related pulmonary toxicity in advanced NSCLC patients. Relevant trials were identified from the databases of Pubmed, Embase, Cochrane Library, and the clinicaltrials.gov of the U.S. National Institutes of Health. The outcomes included the overall incidence, odds ratios (ORs), and 95% confidence intervals (CIs). Fixed-effects models were used in the statistical analyses according to the heterogeneity of the included studies. According to the data from the included trials, the overall incidence of high-grade hemoptysis, pneumonia, pneumonitis, and interstitial lung disease (ILD) was 0.49% (95% CI: 0.24%-0.99%), 2.33% (95% CI: 1.47%-3.66%), 2.24% (95% CI: 1.34%-3.72%), and 1.43% (95% CI: 0.98%-2.09%), respectively. The pooled ORs of high-grade hemoptysis, pneumonia, pneumonitis, and ILD were 1.73 (95% CI: 0.46-6.52; P = 0.42), 0.99 (95% CI: 0.66-1.49; P = 0.95), 4.70 (95% CI: 1.48-14.95; P = 0.0087), and 2.64 (95% CI: 1.22-5.69; P = 0.01), respectively. Gefitinib was associated with a significantly increased risk of high-grade/fatal ILD and pneumonitis compared with the controls, whereas the risk of other high-grade pulmonary events (pneumonia and hemoptysis) was not significant. Careful surveillance of gefitinib-related pulmonary toxicity is critical for the safe use of this drug.

Re-administration of gefitinib following diffuse interstitial lung disease in a patient with advanced lung adenocarcinoma: A case report and review of the literature

Interstitial lung disease (ILD) is a severe adverse effect of gefitinib treatment. Re-administration of gefitinib to patients suspected of suffering from gefitinib-induced ILD requires cautious consideration. In the majority of cases, gefitinib is not re-administered to such patients. The present study reports a case of advanced lung adenocarcinoma, where the patient developed gefitinib-induced ILD and gefitinib was re-administered at 3.5 months after discontinuation of gefitinib treatment. Initially, the patient achieved partial clinical remission, but developed diffuse ILD following gefitinib administration for 5 months. Following the onset of ILD, gefitinib was discontinued immediately and low-dose corticosteroids were administered at the early stages of ILD. Subsequent to recovery from the lung injury, gefitinib was re-administered along with N-acetylcysteine. The patient presented with good lung adenocarcinoma control and did not experience a recurrence of ILD for >16 months. Thus, early discontinuation and gefitinib re-administration with N-acetylcysteine may be a potential novel treatment strategy for gefitinib-induced ILD.

Gefitinib-induced interstitial pneumonia: A case report and review of the literature

The aim of this study was to explore the clinical characteristics of and treatment strategies for interstitial pneumonia induced by gefitinib in patients with advanced non-small cell lung cancer (NSCLC). The detailed clinical data of one patient with NSCLC and gefitinib-induced interstitial pneumonia were compiled and a review of relevant previous studies was performed. Based on this case report and the review, the clinical characteristics, mechanisms and treatment strategies of this rare disease were analyzed. The analyses showed that older, male patients with a long smoking history, high smoking index and adenocarcinoma (particularly bronchoalveolar carcinoma) were more likely to suffer from interstitial pneumonia while taking gefitinib. The onset time of interstitial pneumonia was 1–2 months subsequent to gefitinib administration. The clinical manifestations included chest tightness, shortness of breath, progressive dyspnea, severe hypoxemia and respiratory failure. Diffuse infiltration and alveolar interstitial shadows were observed on the chest tomography scan. In such circumstances, a timely judgment is required, in addition to the withdrawal of gefitinib treatment and the administration of high-dose glucocorticoids, as well as oxygen inhalation and anti-infective therapies, in order to relieve the symptoms. In conclusion, following the onset of gefitinib-induced interstitial pneumonia, the discontinuation of gefitinib is likely to alleviate the suffering of the majority of patients. Early interstitial pneumonia is not an absolute index for the permanent discontinuation of gefitinib treatment. It is necessary to comprehensively consider the benefits and hazards of gefitinib for the patients.

Panitumumab-induced interstitial lung disease in a case of metastatic colorectal cancer

BACKGROUND

A Japanese postmarketing survey of panitumumab revealed that panitumumab-associated interstitial lung disease (ILD) occurred in approximately 1% (19/1767) of patients, causing death in 36.8% of these cases.

CASE REPORT

We report the case of a 60-year-old Japanese man who developed ILD associated with panitumumab therapy (third-line therapy) for metastatic sigmoid colon cancer involving the liver, lymph nodes, and lungs. 2 months after the initiation of panitumumab therapy, he developed a progressive nonproductive cough, dyspnea, and a fever, and was diagnosed with ILD. Intravenous pulse methylprednisolone treatment led to quick recovery. The patient had some risk factors for ILD associated with epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors.

CONCLUSION

Further studies are required to elucidate the association between anti-EGFR antibodies and ILD.

Gefitinib-related interstitial lung disease in Taiwanese patients with non-small-cell lung cancer

BACKGROUND

Gefitinib (Iressa; AstreZeneca, Wilmington, DE) is effective in the treatment of NSCLC, especially in the Asian population. However, ILD is usually a serious pulmonary adverse effect and almost leads to cessation of gefitinib treatment. In this study, we investigated the incidence, clinical features, and prognosis of gefitinib-related ILD in Taiwanese patients with NSCLC.

PATIENTS AND METHODS

This was a retrospective observational study conducted in 2 medical centers and a local teaching hospital.

RESULTS

A total of 1080 patients with NSCLC, who received at least 1 dose (250 mg per day) of gefitinib treatment, were enrolled. Of these, 42 patients were diagnosed with ILD. Twenty-five of the 42 patients were diagnosed with gefitinib-related ILD (incidence, 2.3%). The main manifestations of ILD included dyspnea, cough, and hypoxemia. Six of the 25 patients (24%) with gefitinib-related ILD required invasive mechanical ventilation and all patients were treated with steroids. Twenty-two patients (88%) discontinued gefitinib treatment without further rechallenge. Ten (40%) patients died directly from ILD and in-hospital mortality was 52%. Eleven patients received subsequent cytotoxic chemotherapy with a mean of 33.5 days after ILD events. Kaplan-Meier analysis demonstrated that gefitinib nonresponder and gefitinib use rather than first-line treatment were associated with poor prognosis when ILD developed during gefitinib treatment.

CONCLUSION

Taiwanese patients with NSCLC had a relatively high incidence of ILD during gefitinib treatment. Gefitinib-related ILD is usually life-threatening, especially in gefitinib nonresponders and gefitinib use rather than first-line treatment.

Successful treatment of gefitinib-induced acute interstitial pneumonitis with high-dose corticosteroid: a case report and literature review

Cytotoxic chemotherapy offers a modest benefit for patients with advanced non-small cell lung cancer (NSCLC), with response rates of 20-35% and median survival of 10-12 months. Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs), gefitinib and erlotinib are active against lung cancer. In retrospective studies, EGFR-TKI therapy among patients harboring EGFR mutations showed response rates higher than 65% and a median survival of 20-30 months. Gefitinib is well tolerated and less toxic compared to conventional cytotoxic drugs, but gefitinib-related interstitial lung disease (ILD) has been reported as a serious adverse effect. Although the mechanism remains unknown, multivariate analysis revealed male sex, history of smoking, and the coexistence of interstitial pneumonia or pre-existence of pulmonary fibrosis and poor performance status were all significant risk factors. Here, we reported a case of gefitinib pneumonitis with severe hypoxemia and impending respiratory failure who showed poor response to intermediate dose of systemic steroids but good recovery with high-dose pulse therapy.

Gefitinib-induced interstitial lung disease-addition of intravenous cyclophosphamide to corticosteroids is a valuable treatment option: A case report

A 77-year-old woman was diagnosed as having advanced non-small cell lung cancer, and was started on treatment with gefitinib. Fifty days after the start of treatment, the patient was admitted to the hospital with complaints of dry cough, fever, and shortness of breath. A diagnosis of gefitinib-induced interstitial lung disease was made, and administration of high-dose prednisolone (1 g/day of intravenous methylprednisolone for three consecutive days, followed by oral prednisolone at 50 mg/day) was started. Although progression to respiratory failure could be stopped by the corticosteroid treatment, there was still no improvement in either the lung opacities seen on radiologic imaging, or in the symptoms; moreover, the patient developed corticosteroid-induced myopathy. Therefore, in order to allow reduction of the daily steroid dose, the patient was started on intravenous cyclophosphamide (500 mg/day). This additional treatment allowed the daily dose of oral prednisolone to be reduced to 15 mg/day. Thus, it is considered that intravenous cyclophosphamide may be a valid treatment option for gefitinib-induced lung injury.

Gefitinib-induced pneumonitis in non-small cell lung cancer: radiological and clinical findings in five patients

PURPOSE

The objective of this study was to describe the radiological and clinical features of gefitinib-induced pneumonitis in non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Five patients who suffered dyspnea after gefitinib treatment were selected. Chest radiographs and computed tomography (CT) findings, along with clinical course, were evaluated.

RESULTS

Patients complained of subacute dyspnea and hypoxia. Three patients improved after discontinuation of gefitinib, while remaining two showed no response. Unilateral or bilateral ground glass opacity was observed on chest radiographs and CT.

CONCLUSION

Radiological findings of gefitinib-induced pneumonitis were nonspecific, but radiologists should be aware of this adverse reaction, which can appear during the treatment in NSCLC patients.