Emerging Risk Profile of Lung Cancer Therapy: Diffuse Alveolar Hemorrhage from Osimertinib

Colonic mucosal diffuse congestion associated with Osimertinib

INTRODUCTION

Non-small cell lung cancer (NSCLC) is the most common histological subtype of lung cancer. Osimertinib has been recommended as first-line treatment of advanced NSCLC with EGFR mutations. Previous studies have only reported cases of gastrointestinal bleeding due to Erlotinib and gefitinib, but to date, always no cases of gastrointestinal bleeding due to Osimertinib have been reported.

CASE REPORT

We report a case of a female patient with NSCLC with EFGR mutation. After 1.5 years of treatment with Osimertinib, a colonoscopy showed diffuse congestion of the colonic mucosa.

MANAGEMENT AND OUTCOME

The patient's symptoms of blood in the stool disappeared, after stopping Osimertinib and giving mucosal protection treatment for 1 week.

DISCUSSION

Osimertinib may have contributed to gastrointestinal bleeding because no recurrent bleeding was observed after discontinuation of treatment. Physicians and patients should be aware that osimertinib may increase the risk of gastrointestinal bleeding.

Intestinal Haemorrhage and Colitis Induced by Treatment With Osimertinib for Non-Small-Cell Lung Carcinoma: A Case Report

Background: Osimertinib is recommended either as the first-line therapy for sensitizing EGFR-mutations (FLAURA trial) or at progression to first-/second-generation EGFR inhibitors in the presence of resistance mutation T790M (AURA 3 study). It can effectively improve the prognosis of patients with NSCLC with manageable adverse reactions. Among adverse events, intestinal haemorrhage is rare and requires extensive study on its potential lethality.

Case presentation: A 59-year-old female, diagnosed with relapsed stage IV (cT4N2M1c) NSCLC with T790M mutation of the EGFR gene, received osimertinib treatment. Eight months after osimertinib treatment, she complained of lower abdominal pain and haematochezia without haemorrhoids. Potential causes of intestinal haemorrhage other than osimertinib toxicity were ruled out. Colonoscopy examination showed severe colitis with grade 3 CTCAE. Osimertinib was discontinued, and prednisone 0.5 mg/kg was administered. Follow-up endoscopy showed no pathological findings. A novel third-generation EGFR-TKI, aumolertinib, was administrated. Five months after aumolertinib initiation, CT evaluation showed stable disease (SD), and this patient was free of colitis recurrence.

Conclusion: To our knowledge, this is the first case report of severe colitis as an adverse event associated with osimertinib. Although osimertinib is the standard treatment for NSCLC in patients with T790M mutation and has fewer side effects, colitis may occur after months of treatment. Aumolertinib, a novel third-generation EGFR-TKI, might be an effective alternative for the treatment of patients with NSCLC experiencing colitis from osimertinib.

Osimertinib-Induced Unilateral Diffuse Alveolar Hemorrhage in a Patient With Pulmonary Adenocarcinoma

A 70-year-old man with lung adenocarcinoma was admitted to our hospital due to progressive dyspnea, 4 months after osimertinib initiation. His chest radiograph and computed tomography revealed ground-glass opacities and consolidations dominantly in the upper left lung. He took neither antiplatelet nor anticoagulation agent. No abnormality in coagulation was detected. Bronchoalveolar lavage fluid (BALF) became serially and increasingly hemorrhagic, and confirmed the diagnosis of alveolar hemorrhage. After steroid pulse therapy and withdrawal of osimertinib, his condition gradually improved, accompanied by regression of ground-glass opacities and consolidations. Osimertinib causes not only interstitial pneumonia but also alveolar hemorrhage. The consolidations may spread not bilaterally, but be localized unilaterally. We have to keep this rare adverse event in mind, and consider immediate withdrawal of osimertinib and treatment with steroid. Increased lymphocytes in the BALF may be a potential indicator of sensitivity to steroid and favorable prognosis in diffuse alveolar hemorrhage.

Successful Rechallenge with Osimertinib after Very Acute Onset of Drug-Induced Pneumonitis

Drug-induced interstitial lung disease (DI-ILD) is a rare, yet life-threatening complication associated with tyrosine-kinase inhibitor (TKI) therapy. Third-generation epidermal growth factor receptor-TKI, osimertinib use can be associated with a benign radiological finding called transient asymptomatic pulmonary opacities that can be confused with an infectious pulmonary process resulting in overtreatment with antibiotics or premature treatment withdrawal or severe DI-ILD. In this case, our patient with newly diagnosed metastatic non-small cell lung cancer on treatment with osimertinib developed very early onset severe DI-ILD (grade-IV) with a unique pattern of pulmonary involvement and was treated with high-dose corticosteroids with a response. She was later successfully rechallenged with osimertinib and responded well to the treatment. Our case highlights the importance of being cognizant of the possibility that DI-ILD can rarely occur within a week of treatment initiation with osimertinib and safe reintroduction of the drug is possible in select patients following complete resolution of pulmonary radiographic findings and clinical symptoms even with high-grade adverse events.