Progressive Multiple Cystic Changes in Both Lungs in a Patient Treated with Gefitinib for Lung Adenocarcinoma with Multiple Lung Metastases
A 56-year-old female never-smoker initially developed persistent cough, sputum and progressive dyspnea approximately 1 month before the diagnose NSCLC stage IV. The radiograph and computed tomography (CT) of the chest showed a 2.2-cm soft tissue mass in the right upper lobe with multiple small nodules in the bilateral lungs. A case of lung adenocarcinoma with bilateral intrapulmonary metastases was diagnosed. The patient received two courses of systemic chemotherapy with paclitaxel and cisplatin. However, the chemotherapy had to be discontinued due to paclitaxel-induced hypersensitivity reaction. Thereafter the patient refused further chemotherapy. One year later, after receiving two cycles of first-line chemotherapy, the patient visited the emergency room with an abrupt onset of stuttering, quadriparesis and dyspnea. A spontaneous pneumothorax in the left lung and multiple brain metastases were noted. After a chest tube insertion in the left lung and a 30-Gy whole brain irradiation for brain metastases, the treatment with gefitinib was started with a 250-mg daily dosage and continued for the following 15 months because the patient showed an improvement of symptoms and pulmonary function. Although the primary mass in the right upper lobe with multiple metastatic nodules slightly decreased in size after one month gefitinib treatment, the development of new multiple cystic changes was detected on the follow-up high-resolution CT (HRCT) scan. The pulmonary function 9 months after the initiation of gefitinib therapy showed combined severe obstructive and restrictive ventilatory disturbances (predicted forced expiratory volume at timed interval of 1 second [FEV1] 36%, predicted forced vital capacity [FVC] 31%). Due to a poor performance status neither bronchoalveolar lavages nor histological evaluations were available. In contrast to the gradual progression of parenchymal cystic changes in both lungs were on the follow-up chest CT scan a radiographic regression of the main lesion of NSCLC and metastatic nodules noted (). Simple chest radiographs showed diffuse multiple various sized thin walled cysts and illdefined nodules in bilateral hemi-thorax after the gefitinib therapy. A fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography scan taken 7 months after the use of gefitinib demonstrated a significant increased FDG uptake in the primary lesion only. No uptake was seen in other areas of both lungs, suggesting an interval improvement of metastatic lesions (). Because the patient's condition was tolerable with improved respiratory symptoms, the therapy with gefitinib was continued for 15 months with the patient's approval, despite of the air cystic changes in both lungs. During the follow-up period, neurologic recovery was noted and the patient underwent pulmonary and physical rehabilitation therapies. A follow-up pulmonary function was performed 13 months after the initiation of gefitinib therapy and more improvement was shown than after 9 months (FEV1, 56%; FVC, 53% vs. FEV1, 36%; FVC, 31%) respectively.