Case Report
A 53-year-old woman presented to the hospital with a chief complaint of
abdominal pain. Contrast-enhanced computed tomography (CT) revealed a
large tumor on the right lobe of the liver, multiple lung tumors,
multiple enlarged lymph nodes, and peritoneal dissemination. A liver
tumor biopsy was performed, which confirmed ICC. Therefore, the patient
was diagnosed with unresectable ICC (cT4N1M1, cStage IVB). The patient
had a history of gastric ulcers but without a family history of cancer,
medication maintenance, and allergies. Due to extensive metastasis and
declining performance status, the patient was treated with S-1 (100
mg/day) as the first-line treatment. Progressive disease (PD) due to
increased pulmonary metastasis and peritoneal dissemination by
Response Evaluation Criteria in
Solid Tumors (RECIST) version 1.1 was observed after 5 months of S-1
treatment, and gemcitabine of 500–800 mg/m2/day +
cisplatin of 13–20 mg/m2/day (GC) therapy was started
as the second-line treatment. GC therapy was administered for 11 months;
however, PD due to increased bone metastasis and peritoneal
dissemination occurred. Therefore, CGP was performed to identify
treatment options. The specimen from the initial liver tumor biopsy
performed to diagnose ICC was insufficient for CGP submission. Thus,
liver tumor biopsy and CT-guided lymph node biopsy were performed to
inspect CGP; however, a viable specimen could not be obtained.
Therefore, liquid CGP (FoundationOne® Liquid CDx, Foundation Medicine,
Cambridge, USA) was performed, and FGFR2 fusion was detected. The
results revealed that this patient could use pemigatinib (13.5 mg/day)
as the third-line treatment. Two months after initiating pemigatinib, a
CT scan showed controlled intrahepatic lesions and other distant
metastases, and the state of the cancer was considered a stable disease
based on RECIST (version 1.1) (Figure 1). However, specific side effects
(nail disorders, hyperphosphatemia, and taste disorders) should be
addressed after initiating pemigatinib. Because nail disorders were
classified as grade 3 (Criteria for adverse events version 4.0 [CTCAE
ver.4.0]), pemigatinib was reduced to 9.0 mg/day 3 months after
initiating pemigatinib (Figure 2). Nail disorders were managed by
reducing the pemigatinib dosage, administering topical steroids and
moisturizers, and taping in collaboration with the dermatologist.
Hyperphosphatemia was treated with a phosphorus-restricted diet and
lanthanum carbonate. Nutritionists were asked to address taste disorders
and recommended that the patient should eat foods that could be tasted
easily and gargled with warm water. Due to nail disorders and taste
disorders, the pemigatinib dosage was reduced to 4.5 mg/day 2 months
after reducing it to 9.0 mg/day. Despite her recurrent cholangitis and
strong pemigatinib side effects, she managed to continue pemigatinib
with repeated medication withdrawal as needed; however, she died 26
months after being diagnosed with stage IVB ICC. The treatment
progression is shown in Figure 3.