What's your treatment option in a patient with impending respiratory failure due to disseminated lung cancer?

SummaryDiffuse bronchiolo-alveolar cell carcinoma (BAC) with endolymphatic tumor emboli involving whole lung fields was found in a 25-year-old male. He had a history of 6 pack years of smoking. After a thoracoscopic lung biopsy, his condition was aggravated leading to imminent respiratory failure. Although gefitinib is not usually recommended as a first-line chemotherapeutic drug, we decided to use it considering that the added toxicity of conventional drugs would be fatal to him. Surprisingly, the patient showed the dramatic improvement and was able to exercise 1 week after the treatment. The immunostainings for p-Akt and E-cadherin were strongly positive. A deletion mutation (delE746–750) was detected in exon 19 by sequencing. The fluorescent in situ hybridization (FISH) was negative as low trisomy suggesting that the epidermal growth factor receptor (EGFR) mutation is a more reliable finding for prediction of the response to this novel drug, even in a patient with unfavorable clinical characteristics such as male gender and smoker. An EGFR–tyrosine kinase inhibitor (EGFR–TKI), either alone or combined with other chemotherapeutic drugs, should be considered an initial therapeutic option in patients with disseminated lung cancer requiring urgent treatment.