Skip to main content

Main menu

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Peer reviewer login
  • Journal club
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Peer reviewer login
  • Journal club
  • Alerts
  • Subscriptions

First report of a very rare complication in a case of nonsmall cell lung carcinoma

Inês Moreira, Ana Sofia Vilariça, Paula Alves
Breathe 2021 17: 210107; DOI: 10.1183/20734735.0107-2021
Inês Moreira
1Pulmonology Dept, Hospital Santa Marta, Centro Hospitalar Universitário Lisboa Central (CHULC), Lisbon, Portugal
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: ines.sousa.moreira@hotmail.com
Ana Sofia Vilariça
2Pulmonology Dept, Hospital Pulido Valente, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Paula Alves
2Pulmonology Dept, Hospital Pulido Valente, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

While immune checkpoint inhibitors like pembrolizumab are promising agents for nonsmall cell lung carcinoma treatment, increased use is leading to increased immune-related adverse events, including endocrinopathies such as adrenal insufficiency. https://bit.ly/3iMfhUk

A 45-year-old male patient presented with scarcely productive cough with 3 months of evolution without other respiratory complaints, no chest pain and no constitutional symptoms, including no weight loss.

Overall, the patient was in good health. He was a car driver, an active smoker of 60 pack-years and had a medical history of dyslipidaemia and chronic laryngitis. The patient had undergone a splenectomy when he was 25 years old due to abdominal trauma. Additionally, he had a family medical history of breast cancer.

The patient first consulted his primary care physician due to these symptoms. On examination, decreased breath sounds were auscultated in the left upper lobe and oxygen saturation was 96%.

The chest radiograph showed enlargement of the left mediastinum and hypotransparency of the left just-hilar parenchyma. Consequently, a thoracic computed tomography (CT) scan (figure 1) was requested to better characterise the findings. It showed a solid pulmonary nodule in the left upper lobe of 26×24 mm, a pre-vascular adenopathy of 20 mm and small adenopathies in the left hilum.

Figure 1
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1

Thoracic CT scan.

Due to the suspicion of lung cancer, the patient was referred to a pulmonology appointment.

He underwent a positron emission tomography (PET) scan (figure 2) that showed uptake with high metabolism at the level of the left upper lobe lesion and in the left pre-vascular and ipsilateral hilar ganglia. No other alterations were found in other locations.

Figure 2
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2

PET scan.

To obtain the histological diagnosis, he underwent a bronchofibroscopy. In the left bronchial tree, at the level of division B1/B2, a small polypoid formation was identified. At this level, bronchoalveolar lavage, bronchial brushing, bronchial biopsies and transbronchial biopsies were performed. The cytology of all samples was negative.

Given the negative result of the cytology, an endobronchial echo-endoscopy was performed to obtain a histological diagnosis and to determine mediastinal staging. Systemic exploration of ganglion stations was carried out, with ganglion identification at station level 4 L (lower paratracheal), 10 L (pulmonary) and 11 L (pulmonary). Due to technical impossibility, 10 L punctures were not performed; in stations 4 L and 11 L, immunohistochemistry was positive for CK7 and TTF-1 and negative for CK20 and p40. These findings favoured the diagnosis of lung adenocarcinoma.

The patient had positive expression (>50%) of the programmed cell death ligand 1 (PD-L1). Epidermal growth factor receptor mutations, anaplastic lymphoma kinase rearrangements and c-ros oncogene 1 rearrangements were not detected.

It should be noted that there was no evidence of metastases in the brain CT scan, and only a chronic inflammatory component in the right mastoid and slight inflammatory changes in the sinuses were observed.

Task 1

According to the American Joint Committee on Cancer (AJCC), tumour, nodes and metastases (TNM) classification for nonsmall lung cancer (8th edition), which is the staging in this case?

  • a) cT2bN3M0 (stage IIIB)

  • b) cT1bN1M0 (stage IIB)

  • c) cT1cN2M0 (stage IIIA)

  • d) cT2aN2M0 (stage IIIA)

Answer 1

c. The correct staging is cT1cN2M0. T1c since the extent of the primary tumour was >2 cm but <3 cm, it did not involve the main bronchus, the carina, the visceral pleura or other mediastinal structures and it was not associated with atelectasis or post-obstructive pneumonitis; N2 because it affected ipsilateral mediastinal nodules; and M0 because the staging exams didn't find distant metastasis.

Task 2

According to the data we have so far, which treatment would you consider?

  • a) Neoadjuvant chemotherapy

  • b) Video-assisted thoracic surgery (VATS) left upper lobectomy with systematic lymphadenectomy

  • c) First-line immunotherapy with pembrolizumab

  • d) Combination of pembrolizumab and chemotherapy

Answer 2

a. The case was presented and discussed in a multidisciplinary meeting of thoracic oncology. Since the patient had an adenocarcinoma of the upper left lobe, with clinical staging IIIA (T1cN2M0), with positive expression of PD-L1 (>50%) and without other mutations, the decision was to perform three cycles of neoadjuvant chemotherapy (with cisplatin and vinorelbine) and then to repeat the imaging evaluation.

The patient completed three cycles with good tolerance and without complications. He was also successfully referred to a smoking cessation consultation.

Reassessment CT was performed after chemotherapy. A reduction of the left upper lobe nodule and of hilar adenopathies was observed. However, superior mediastinal lymph nodes (2R - right upper paratracheal) were enlarged.

The case was discussed again in a thoracic oncology multidisciplinary meeting. Given the adenopathy in the aorto–pulmonary window with pathological imaging criteria, it was decided to perform a video-assisted mediastinoscopic lymphadenectomy (VAMLA). Thus, after the three cycles of neoadjuvant chemotherapy, the VAMLA-extracted 4L-lymph nodes (as well as 2R, 4R and 7-lymph nodes) showed complete pathological regression.

As the patient had Eastern Cooperative Oncology Group (ECOG) Performance Status 0 and no respiratory function contraindication for lung surgical resection, a left upper lobectomy with systematic mediastinal lymph node resection by posterior thoracotomy was performed with curative intent, without any major complications.

After surgical resection the pathological (p)TNM was pT2aN2. The World Health Organization (WHO) subtype of adenocarcinoma was solid-predominant adenocarcinoma of the lung. Additional molecular testing was performed on the resected operating piece and showed no epidermal growth factor receptor mutations, anaplastic lymphoma kinase rearrangements and c-ros oncogene 1 rearrangements.

Afterwards, the patient underwent sequential adjuvant chemotherapy and radiotherapy. He completed four cycles of adjuvant chemotherapy with cisplatin and vinorelbine, with good tolerance and without complications. He completed adjuvant radiotherapy, completing the total dose of 50 Gy·25 Fr−1, with good tolerance and with no associated toxicity.

Follow-up of the patient was conducted by performing thoracoabdominal CT scan and analytical studies, which evaluated tumour markers. 4 months after completing sequential adjuvant chemotherapy and radiotherapy, the CT scan showed disease recurrence, with suspicion of hepatic, renal, and adrenal metastasis as well as intra-abdominal and retroperitoneal adenopathies (figure 3).

Figure 3
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 3

Abdominal CT scan.

Task 3

In this case, what is the indicated treatment for lung cancer recurrence, now staging IVB?

  • a) Liquid biopsy to search for next-generation sequencing (NGS) gene panel

  • b) First-line immunotherapy with pembrolizumab

  • c) Combination of pembrolizumab and chemotherapy

  • d) Second-line chemotherapy

Answer 3

b. The patient was proposed for first-line immunotherapy with pembrolizumab, as the (neo)adjuvant chemotherapy was not counted as first line.

Tissue biopsy of the metastatic sites or liquid biopsy were not performed, since there was such a recent anatomopathological study of the operating piece with molecular testing and the patient was a heavy smoker, so it was considered by the multidisciplinary team that the risk of delaying the start of treatment would outweigh its benefit.

Up to the 10th cycle of treatment, he showed a partial response. Subsequently he maintained stable disease until the 26th cycle of treatment.

In the appointment scheduled for the 26th cycle of pembrolizumab treatment, the patient reported asthenia, dizziness, mental confusion, and back pain with progressive worsening. The patient had recently undergone antibiotic therapy with ciprofloxacin for a urinary infection and the analytical study found no increase in inflammatory parameters and a normal urinalysis. However, it indicated a new onset of thyroid dysfunction (increased thyroid-stimulating hormone levels, 7.48 mIU·L−1, and decreased free T4 levels, 0.46 ng·dL−1). In the last thoracoabdominal CT scan (figure 4) a partial response (with disappearance of the hepatic nodules) was observed.

Figure 4
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 4

Abdominal CT scan.

At this point, the patient started medication with levothyroxine 50 μg. A cranioencephalic CT scan was requested to study the neurological condition and treatment with pembrolizumab was maintained.

However, the patient resorted to an unscheduled appointment with complaints of anorexia as he had lost 10 kg in the previous month. The patient failed to attend the cranioencephalic CT scan appointment.

An urgent analytical study was requested, which revealed worsening of thyroid dysfunction despite supplementation (increased thyroid-stimulating hormone levels, 21.8 mIU·L−1 (normal range: 0.35–4.94 mIU·L−1), and decreased free T4 levels, 0.46 ng·dL−1 (0.70–1.48 ng·dL−1)) and a new onset of hyponatraemia (Na+ 129 mEq·L−1).

Task 4

Which step would you take next?

  • a) Decrease the dose of levothyroxine

  • b) Discontinue pembrolizumab treatment

  • c) Change for second-line treatment with chemotherapy

  • d) Screen for hidden neoplasia

Answer 4

d. As indicated by the endocrinology specialist, the levothyroxine dose was increased to 75 μg. The patient maintained pembrolizumab treatment. To screen for hidden neoplasia a PET-CT scan, an upper digestive endoscopy and a colonoscopy were requested.

At the appointment scheduled for the 31st cycle of treatment, the patient maintained the same clinical condition and had suspended levothyroxine on his own initiative. The analytical study revealed worsened hypothyroidism (increased thyroid-stimulating hormone levels (88.3 mIU·L−1) and decreased free T4 levels (0.05 ng·dL−1)) and hyponatraemia (Na+ 124 mEq·L−1). The PET-CT did not show evidence of metabolically active disease (figure 5). So, there was complete response with the disappearance of the hepatic, renal and adrenal metastases as well as intra-abdominal and retroperitoneal adenopathies. Given these results, the patient was referred to the endocrinology emergency department. However, the patient did not attend this specialised consultation. At this time, the patient underwent the last cycle of treatment with pembrolizumab.

Figure 5
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 5

PET scan.

In the following scheduled appointment, the patient was asthenic, presenting with mental confusion and arterial hypotension. The analytical study showed hypothyroidism improvement (thyroid-stimulating hormone 32.2 mIU·L−1 and free T4 0.52 ng·dL−1), but severe hyponatraemia (Na+ 115 mEq·L−1). He was hospitalised for metabolic compensation and an aetiological study was conducted.

Task 5

Which aetiology would you most suspect?

  • a) Central nervous system metastisation

  • b) Syndrome of inappropriate antidiuretic hormone secretion

  • c) Iatrogenic adrenocorticotropic hormone (ACTH) deficiency caused by pembrolizumab

  • d) Tertiary hypothyroidism

Answer 5

c. Laboratory data revealed a low level of cortisol (0.1 μg·dL−1) accompanied by an inappropriately low ACTH (<1 pg·mL−1). Pituitary magnetic resonance imaging (MRI) showed diffuse substantial gadolinium enhancement, T2 hyperintensity, loss of pituitary bright spot, but no pituitary enlargement. Serum cortisone and ACTH levels were low throughout the day and urinary free cortisol excretion fell below the lower limit of normal. There was no ACTH and cortisol response in the corticotrophin-releasing hormone test. Therefore, isolated ACTH deficiency was diagnosed and hypophysitis was the suspected aetiology, although there was no pituitary enlargement in the pituitary MRI. Given the presence of another altered pituitary series in addition to the thyroid one, although less frequent, the hypothesis of hypothyroidism secondary to hypophysitis could also be considered. An immune-related adverse event (irAE) induced by pembrolizumab was the most likely cause of this condition.

The patient was treated with corticosteroid therapy, initially in higher doses and intravenously, with progressive weaning, and was discharged under levothyroxine 100 μg and prednisolone 7.5 mg and referred for an endocrinology consultation.

Currently, the patient maintains the treatment suspended, not only due to the immune-mediated toxicity, but also to the fact that he has completed more than 2 years of treatment. The patient maintains follow-up, with no locoregional relapse or distant metastases.

Discussion

Lung cancer is a leading cause of cancer-related mortality, with the majority of cases being classified as nonsmall cell lung carcinoma (NSCLC).

Programmed cell death 1 (PD-1), PD-L1 and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) are targets for immune checkpoint inhibition. This inhibition, explored in cancer immunotherapy used to treat NSCLC, results in enhanced peripheral T-cell immunity [1].

Pembrolizumab, an anti-PD-1 IgG4 monoclonal antibody, has been recommended as first-line monotherapy for advanced NSCLC with high PD-L1 expression and without targetable driver gene mutations, due to superiority over conventional platinum-based chemotherapy for both progression-free and overall survival [2, 3].

While immune checkpoint inhibitors are promising agents for cancer treatment, their increased use is leading to the increase of the number of irAEs cases, including endocrinopathies (i.e. thyroid disfunction, autoimmune diabetes, hypophysitis, hypopituitarism, anterior pituitary insufficiency, primary or secondary adrenal insufficiency) [3–5].

Usually, irAEs develop within a period that can span from a few weeks to months after the first administration of immune checkpoint inhibitors. Up to 29% of patients who have been treated with immune checkpoint inhibitors show signs of endocrine disorder after the sixth or seventh week, with a median onset time of 7–20 weeks [6, 7]. The incidence of endocrine disorders is low for anti-PD-1 monotherapy [8]. The likelihood of irAEs is said to be higher in patients with autoimmune disease, organ or haematopoietic stem cell transplants, chronic viral infection, organ dysfunction or advanced age [9].

Adrenal insufficiency is a very rare irAE, with an incidence <4.3% [10, 11]. There are only two previous reports showing isolated ACTH deficiency caused by pembrolizumab, one for squamous cell lung carcinoma and the other for metastatic colon cancer [12, 13].

Clinical characteristics and mechanisms of secondary adrenal insufficiency specifically associated with pembrolizumab treatment remain unclear because of the rarity of this adverse effect [13].

Adrenal insufficiency presents with nonspecific symptoms, such as fatigue (the most common symptom, reported by 16–24% of patients), nausea, vomiting, weakness, anorexia, hypotension, headache, weight loss, abdominal pain or fever [12].

Hypophysitis is a possible aetiology. Hypophysitis is a well-known endocrine irAE, but its incidence varies with the immune checkpoint inhibitor agent employed. A recent systematic review and meta-analysis reported that hypophysitis was rarely observed in patients treated with PD-1 or PD-L1 inhibitors. However, hypophysitis occurs more frequently in patients under combination therapy of CTLA-4 and PD-1 inhibitors and in patients treated with CTLA-4 inhibitors alone [13].

There are two types of adrenal insufficiency: primary and secondary. If adrenal insufficiency due to immune checkpoint inhibitors is suspected, it is important to confirm serum cortisol, ACTH, aldosterone and renin levels. Early morning serum cortisone levels <3 µg·dL−1 are indicative of adrenal insufficiency [14]. Other hormone levels, such as thyroid-stimulating hormone, free thyroxine, free triiodothyronine, gonadotrophins and testosterone should be checked for an accurate diagnosis [13]. A retrospective cohort study indicated that eosinophilia is an early indicator of ACTH deficiency during PD-1 inhibitor treatment [13]. MRI with gadolinium contrast is very useful to diagnose the main differential diagnosis of primary cause, brain metastasis [15].

Early recognition of hypophysitis and subsequent ACTH deficiency is mandatory because it is potentially life-threatening, in case of an adrenal crisis, but remediable by systemic corticosteroids. An initial dose of corticosteroid of 12 mg·kg−1·day−1 for 3 days could be administered, and then tapered gradually over a period of at least 1 month [16]. In case of persistence, immunosuppressive drugs such as anti-tumour necrosis factor-α, mycophenolate mofetil and antithymocyte immunoglobulins can be used. Since endocrine-related adverse events are irreversible, patients with adrenal insufficiency are treated with long-term corticosteroids. Additional complications should be carefully sought and treated, such as cushingoid features, osteoporosis, glaucoma, muscle weakness and opportunist infections [12].

Further cases need to be documented to fully comprehend the characteristics of the disease and clinical course, in order to optimise the follow-up of these patients.

Footnotes

  • Conflict of interest: I. Moreira has nothing to disclose.

  • Conflict of interest: A.S. Vilariça has nothing to disclose.

  • Conflict of interest: P. Alves has nothing to disclose.

  • Received July 17, 2021.
  • Accepted October 5, 2021.
  • Copyright ©ERS 2022
http://creativecommons.org/licenses/by-nc/4.0/

Breathe articles are open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

References

  1. ↵
    1. Topalian SL,
    2. Hodi FS,
    3. Brahmer JR, et al.
    Safety, activity, and immune correlates of anti-PD-1 antibody in cancer. N Engl J Med 2012; 366: 2443–2454. doi:10.1056/NEJMoa1200690
    OpenUrlCrossRefPubMed
  2. ↵
    1. Reck M,
    2. Rodriguez-Abreu D,
    3. Robinson AG, et al.
    Pembrolizumab versus chemotherapy for PD-L1-positive non-small-cell lung cancer. N Engl J Med 2016; 375: 1823–1833. doi:10.1056/NEJMoa1606774
    OpenUrlCrossRefPubMed
  3. ↵
    1. Reck M,
    2. Rodriguez-Abreu D,
    3. Robinson AG, et al.
    Updated analysis of KEYNOTE-024: pembrolizumab versus platinum-based chemotherapy for advanced non-small- cell lung cancer with PD-L1 tumor proportion score of 50% or greater. J Clin Oncol 2019; 37: 537–546. doi:10.1200/JCO.18.00149
    OpenUrlCrossRefPubMed
    1. Barroso-Sousa R,
    2. Barry WT,
    3. Garrido-Castro AC, et al.
    Incidence of endocrine dysfunction following the use of different immune checkpoint inhibitor regimens: a systematic review and meta-analysis. JAMA Oncol 2018; 4: 173–182. doi:10.1001/jamaoncol.2017.3064
    OpenUrlPubMed
  4. ↵
    1. Tan MH,
    2. Iyengar R,
    3. Mizokami-Stout K, et al.
    Spectrum of immune checkpoint inhibitors-induced endocrinopathies in cancer patients: a scoping review of case reports. Clin Diabetes Endocrinol 2019; 5: 1. doi:10.1186/s40842-018-0073-4
    OpenUrlPubMed
  5. ↵
    1. González-Rodríguez E,
    2. Rodríguez-Abreu D
    . Spanish Group for Cancer Immuno-Biotherapy (GETICA). Immune checkpoint inhibitors: review and management of endocrine adverse events. Oncologist 2016; 21: 804–816. doi:10.1634/theoncologist.2015-0509
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Weber JS,
    2. Dummer R,
    3. de Pril V, et al.
    Patterns of onset and resolution of immune-related adverse events of special interest with ipilimumab: detailed safety analysis from a phase 3 trial in patients with advanced melanoma. Cancer 2013; 119: 1675–1682. doi:10.1002/cncr.27969
    OpenUrlCrossRefPubMed
  7. ↵
    1. Robert C,
    2. Schachter J,
    3. Long GV, et al.
    Pembrolizumab versus ipilimumab in advanced melanoma. N Engl J Med 2015; 372: 2521–2532. doi:10.1056/NEJMoa1503093
    OpenUrlCrossRefPubMed
  8. ↵
    1. Johnson DB,
    2. Sullivan RJ,
    3. Menzies AM
    . Immune checkpoint inhibitors in challenging populations. Cancer 2017; 123: 1904–1911. doi:10.1002/cncr.30642
    OpenUrlPubMed
  9. ↵
    1. Doi T,
    2. Piha-Paul SA,
    3. Jalal SI, et al.
    Pembrolizumab (MK-3475) for patients (pts) with advanced esophageal carcinoma: preliminary results from KEYNOTE-028. J Clin Oncol 2015; 33: Suppl. 15, 4010. doi:10.1200/jco.2015.33.15_suppl.4010
    OpenUrl
  10. ↵
    1. Ribas A,
    2. Puzanov I,
    3. Dummer R, et al.
    Pembrolizumab versus investigator-choice chemotherapy for ipilimumab-refractory melanoma (KEYNOTE-002): a randomised, controlled, phase 2 trial. Lancet Oncol 2015; 16: 908–918. doi:10.1016/S1470-2045(15)00083-2
    OpenUrlCrossRefPubMed
  11. ↵
    1. Bekki T,
    2. Takakura Y,
    3. Kochi M, et al.
    A case of isolated adrenocorticotropic hormone deficiency caused by pembrolizumab. Case Rep Oncol 2020; 13: 200–206. doi:10.1159/000505687
    OpenUrl
  12. ↵
    1. Tanaka S,
    2. Kushimoto M,
    3. Nishizawa T, et al.
    Isolated ACTH deficiency during single-agent pembrolizumab for squamous cell lung carcinoma: a case report. Clin Diabetes Endocrinol 2020; 6: 1. doi:10.1186/s40842-019-0092-9
    OpenUrl
  13. ↵
    1. Hägg E,
    2. Asplund K,
    3. Lithner F
    . Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency. Clin Endocrinol (Oxf) 1987; 26: 221–226. doi:10.1111/j.1365-2265.1987.tb00780.x
    OpenUrlCrossRefPubMed
  14. ↵
    1. Moses AM,
    2. Clayton B,
    3. Hochhauser L
    . Use of T1-weighted MR imaging to differentiate between primary polydipsia and central diabetes insipidus. AJNR Am J Neuroradiol 1992; 13: 1273–1277.
    OpenUrlAbstract/FREE Full Text
  15. ↵
    1. Champiat S,
    2. Lambotte O,
    3. Barreau E, et al.
    Management of immune checkpoint blockade dysimmune toxicities: a collaborative position paper. Ann Oncol 2015; 27: 559–574. doi:10.1093/annonc/mdv623
    OpenUrlPubMed
PreviousNext
Back to top
Vol 17 Issue 4 Table of Contents
Breathe: 17 (4)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
First report of a very rare complication in a case of nonsmall cell lung carcinoma
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
First report of a very rare complication in a case of nonsmall cell lung carcinoma
Inês Moreira, Ana Sofia Vilariça, Paula Alves
Breathe Dec 2021, 17 (4) 210107; DOI: 10.1183/20734735.0107-2021

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
First report of a very rare complication in a case of nonsmall cell lung carcinoma
Inês Moreira, Ana Sofia Vilariça, Paula Alves
Breathe Dec 2021, 17 (4) 210107; DOI: 10.1183/20734735.0107-2021
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Discussion
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

Subjects

  • Lung cancer
  • Respiratory clinical practice
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Expert opinion

  • Lung cancer screening by volume CT
  • In pursuit of the primary
Show more Expert opinion

Case report

  • Recurrent bilateral lung infiltrates in a patient with UC
  • A pregnant woman with severe dyspnoea
  • Persistent pleuritic chest pain in a patient with CF
Show more Case report

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About Breathe

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Intructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN: 1810-6838
Online ISSN: 2073-4735

Copyright © 2023 by the European Respiratory Society