Toxic risk of stereotactic body radiotherapy and concurrent helical tomotherapy followed by erlotinib for non-small-cell lung cancer treatment - case report

A 77-year-old man with stage III NSCLC, received erlotinib 150 mg/day, combined with image-guided SBRT via HT. A total tumor dose of 54 Gy/9 fractions was delivered to the tumor bed. The tumor responded dramatically and the combined regimen was well tolerated. After concurrent erlotinib-SBRT, erlotinib was continued as maintenance therapy. The patient developed dyspnea three months after the combined therapy and radiation pneumonitis with interstitial lung disease was suspected.Combination SBRT, HT, and erlotinib therapy provided effective anti-tumor results. Nonetheless, the potential risks of enhanced adverse effects between radiation and erlotinib should be monitored closely, especially when SBRT is part of the regimen.Erlotinib, one of the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs), is active and relatively well tolerated in chemotherapy-na？ve elderly patients with advanced non-small cell lung cancer (NSCLC) [1]. Image-guided stereotactic body radiotherapy (SBRT) and helical tomotherapy (HT) using hypofractionation in patients with early-stage medically inoperable NSCLC is feasible and well tolerated [2]. For stage III NSCLC, hypofractionation yields equivalent survival rates, but without often fatal symptomatic pneumonitis, compared to conventional radiotherapy [3]. The addition of standard-dose erlotinib to chemoradiotherapy is feasible, without an increase in toxicity [4]. Little information is available on fatal pulmonary toxicity due to irradiation pneumonitis when erlotinib is concurrently given with SBRT and used thereafter as maintenance therapy for NSCLC.A 77-year-old man was diagnosed with NSCLC, cT2N2M0, stage III A. Chest computed tomography (CT) showed a soft tissue mass measuring 4 × 3.9 cm in the right upper lung, with mediastinal lymphadenopathy. Carcinoembryonic antigen (CEA) was also elevated to 12.9 mg/dl. The Patient received oral erlotinib 150 mg/day as the first line therapy. Three months later, the CEA increa