Diffuse Lung Disease: Student/Resident Case Report Poster - Diffuse Lung Disease |

Delayed Trastuzumb (Herceptin)-Related ARDS FREE TO VIEW

Frederick Shrimp, MS; Danielle Behrens, DO; Pius Ochieng, MD
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The Commonwealth Medical College, Scranton, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):525A. doi:10.1016/j.chest.2016.08.539
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SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Antineoplastic agent-induced interstitial pneumonitis is a potentially lethal adverse event for which glucocorticoids are a treatment option although no studies have been conducted that demonstrate benefit. We describe a patient who developed delayed and lethal trastuzumab-related interstitial pneumonitis.

CASE PRESENTATION: A 71-year-old female with Stage IIA invasive lobular carcinoma breast cancer (cT2N0; estrogen, progesterone and HER-2/neu positive) was treated with six courses of docetaxel, carboplatin, pertuzumab and trastuzumab without complication. She was then started on trastuzumab monotherapy and three weeks later, she developed acute hypoxemic respiratory failure with ARDS. Trastuzumab was stopped with no improvement. She was empirically treated with broad-spectrum antibiotics (including empiric Pneumocystis treatment) and antifungal, as she was too unstable for safe bronchoscopy. Having no improvement, she was treated with pulse steroids but failed to respond and died five weeks after presenting with ARDS. Autopsy showed diffuse alveolar damage and organizing pneumonia with negative cultures.

DISCUSSION: The polypharmacy of typical breast cancer treatment presents a challenge in identifying the offending agent in suspected drug-induced pulmonary disease (DIPD). Trastuzumab-related ARDS is rare, affecting 0.6% of recipients of this medication; and risk factors include age over 60 years and co-administration with taxols; but it tends to happen within one month of therapy. Our patient received docetaxel, carboplatin, pertuzumab, trastuzumab and dexamethasone every three weeks for six cycles without symptoms then developed hypoxic pneumonitis eight days after her first trastuzumab monotherapy. It is unclear why the initial six courses of the trastuzumab did not induce DIPD. The clinic-radiological features were not consistent with hypersensitivity-type lung disease or chronic fibrosis/pneumonitis that may be caused by taxanes, thus our impression was trastuzumab-induced ARDS once she failed to respond to antimicrobials. The dexamethasone could have positively mitigated such reaction in the intensive therapy phase but this is not fully explained by her lack of response to pulse steroids. A similar report describes a patient who experienced progressive dyspnea after trastuzumab monotherapy. That patient recovered after prednisone treatment, whereas our patient did not recover despite prednisone treatment.

CONCLUSIONS: Trastuzumab can cause life-threatening infiltrative lung disease for which there is no proven treatment. Low incidence of trastuzumab-related DIPD makes therapeutic trials a challenge.

Reference #1: Camus P, Bonniaud P, Fanton A, et al. Drug-induced and iatrogenic infiltrative lung disease. Clin Chest Med. 2004; 25:479-519.

Reference #2: Pepels M, Boomars K, van Kimmenade R, Hupperets P. Life-threatening interstitial lung disease associated with trastuzumab: case report. Breast Cancer Res Treat. 2009;113:609-612.

DISCLOSURE: The following authors have nothing to disclose: Frederick Shrimp, Danielle Behrens, Pius Ochieng

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