Case Report
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. May 15, 2023; 15(5): 892-901
Published online May 15, 2023. doi: 10.4251/wjgo.v15.i5.892
Acute respiratory distress syndrome and severe pneumonitis after atezolizumab plus bevacizumab for hepatocellular carcinoma treatment: A case report
Su Hyeon Cho, Ga Ram You, Chan Park, Sang-Geon Cho, Jong Eun Lee, Sung Kyu Choi, Sung Bum Cho, Jae Hyun Yoon
Su Hyeon Cho, Sung Kyu Choi, Jae Hyun Yoon, Department of Gastroenterology and Hepatology, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea
Ga Ram You, Sung Bum Cho, Department of Gastroenterology and Hepatology, Hwasun Chonnam National University Hospital and Medical School, Hwasun 58128, South Korea
Chan Park, Jong Eun Lee, Department of Radiology, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea
Sang-Geon Cho, Department of Nuclear Medicine, Chonnam National University Hospital, Hwasun 58128, South Korea
Author contributions: Cho SH, You GR, and Yoon JH contributed to analysis and interpretation of the data and drafting of the article; Park C, Lee JE, and Cho SG contributed to technical and material support; Choi SK and Cho SB contributed to critical revision and final approval of this article; Cho SH and You GR contributed equally to this work as co-first author.
Supported by National Research Foundation of Korea, No. NRF-2021R1F1A1061719.
Informed consent statement: Written informed consent was obtained from the patient’s wife for the publication of this case report and any accompanying images.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jae Hyun Yoon, MD, Associate Professor, Department of Gastroenterology and Hepatology, Chonnam National University Hospital and Medical School, Je-bong ro 42, Dong Gu, Gwangju 61469, South Korea.
Received: January 13, 2023
Peer-review started: January 13, 2023
First decision: January 21, 2023
Revised: February 1, 2023
Accepted: April 7, 2023
Article in press: April 7, 2023
Published online: May 15, 2023

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide and has a high mortality. However, the treatment options for advanced HCC are limited to tyrosine kinase inhibitors, such as sorafenib and lenvatinib. Since previous regimens have an insufficient efficacy, the combination therapy of atezolizumab and bevacizumab (Ate/Bev) has been investigated, which showed an improvement in progression-free and overall survival. However, the adverse events of this combination therapy in advanced HCC have not been established. Herein, we report a novel case of an unresectable HCC and acute respiratory distress syndrome (ARDS) after a combination therapy of Ate/Bev.


An 82-year-old male visited our outpatient clinic for an incidentally detected liver mass. Liver magnetic resonance imaging and enhanced chest computed tomography (CT) were performed, which showed arterial hyperenhancement with washout in delayed phase suggesting HCC, and a well-defined metastatic solid nodule, respectively. F-18 fluorodeoxyglucose positron emission tomography (PET)-CT exhibited multiple hypermetabolic lesions in the iliac bone, lumbar vertebrae, and femur. Because of the high burden of the intrahepatic tumor, transarterial radioembolization was initially performed; after 37 d, a combination therapy of Ate/Bev was administered. The patient visited the emergency department three days after Ate/Bev treatment complaining of dyspnea. He was diagnosed with severe pneumonitis based on CT. Despite administering oxygen via a high-flow nasal cannula, the P/F ratio was only 74; therefore, the patient was diagnosed with ARDS based on the overall examination results. Low tidal volume with high positive end-expiratory pressure, sedative agents combined with a neuromuscular blocker, and a systemic steroid were promptly applied to manage the ARDS. However, the patient did not recover from the hypoxia and expired 31 h after being admitted.


Clinicians should be aware of severe pneumonitis due to the immune-related adverse events of this combination therapy, and patients should be closely monitored after therapy.

Keywords: Hepatocellular carcinoma, Systemic therapy, Adverse events, Pneumonitis, Atezolizumab, Acute respiratory distress syndrome

Core Tip: Nowadays, the combination therapy of atezolizumab and bevacizumab is recommended as the first-line systemic treatment for advanced hepatocellular carcinomas. A global phase III study and recent real-world studies demonstrated rare life-threatening adverse events of atezolizumab and bevacizumab. However, our patient underwent acute respiratory distress syndrome and finally died three days after treatment. To the best of our knowledge, this is the first case of severe respiratory failure resulting in death with a very short interval from atezolizumab and bevacizumab administration. Therefore, we suggest close monitoring of lung toxicity after therapy.