Application of corticosteroid therapy with esophageal cancer: a case report in the treatment of radiation-induced and immune-related pneumonia

Introduction

Radiation pneumonitis (RP) represents a frequent complication following radiotherapy for thoracic malignancies, including lung cancer, breast cancer, and esophageal cancer, with an incidence ranging from 10% to 30% (1,2). In severe cases, RP may progress to radiation-induced pulmonary fibrosis, substantially impacting patients’ quality of life and disease prognosis (3-5). Despite advancements in radiotherapy techniques, such as intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT), which have significantly enhanced target accuracy, the inflammatory response in lung tissue induced by radiation exposure remains unavoidable. Radiation triggers acute interstitial pulmonary edema and chronic fibrosis via alveolar epithelial cell damage, release of pro-inflammatory cytokines [e.g., tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6], and immune cell infiltration. This pathological mechanism provides a theoretical foundation for anti-inflammatory therapeutic strategies.

While glucocorticoids remain the cornerstone of treatment for both RP and immune-related pneumonitis (IRP), their application in this complex scenario is not standardized (6,7). The management becomes particularly challenging in elderly patients, who are more susceptible to severe toxicity and opportunistic infections, such as pulmonary superinfection, which can further mimic or complicate pneumonitis. The key clinical question is no longer whether to use steroids, but how to optimally administer them—navigating the trade-offs between efficacy and the risks of immunosuppression, infection, and delayed recovery—especially when the dominant etiology is unclear (8,9).

Currently, clinical practice relies heavily on expert consensus due to a lack of high-level evidence and standardized protocols for managing these overlapping toxicities. Detailed case reports that document the diagnostic workup, treatment rationale, and follow-up of such complex cases are urgently needed to illuminate these challenges and guide clinical decision-making.

This case report, adhering to CARE guidelines, describes an elderly patient with esophageal cancer who developed severe interstitial pneumonia following combined radiotherapy and immunotherapy. We highlight the intricate process of differentiating between RP, IRP, and potential infection, and detail the subsequent management with an individualized corticosteroid regimen. The value of this report lies not in asserting the efficacy of steroids, but in illustrating a pragmatic approach to a common yet poorly standardized clinical problem, thereby contributing to the ongoing discussion on optimal patient management. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-178/rc).

Case presentation

History

This case report presents a 78-year-old female patient with no documented family history of genetic disorders, who was diagnosed with esophageal cancer approximately 8 months prior to the report. Following 30 sessions of radiotherapy and two cycles of immunotherapy, the patient developed radiation-induced and immune-related interstitial pneumonia. She was subsequently treated with glucocorticoids and other supportive medications, leading to significant symptom relief. The patient then underwent long-term oral glucocorticoid maintenance therapy for a total duration of 3 months. Multiple follow-up imaging examinations revealed no evidence of pulmonary fibrosis.

Patient’s sharing

The patient described her experience after treatment: “Before, I was stuck in bed all day, tied to an oxygen machine. Even simple things like getting dressed or eating would leave me gasping for air—it felt like a heavy weight was pressing on my chest. Now, my body just feels lighter. I can get up and walk around slowly without getting out of breath. But what I’m happiest about is finally being free from that oxygen tube. I feel so much more at ease, and I can breathe smoothly again.”

Therapeutic process

The patient’s treatment timeline is detailed in Table 1. The patient, a 78-year-old female, presented to the hospital on August 5, 2024, with complaints of persistent stomach pain and discomfort lasting over one year. A gastroscopy was performed, revealing an ulcer-like protrusion approximately 25 cm from the incisors in the esophagus, covered with turbid coating. The biopsy sample was fragile, and the esophageal lumen appeared narrowed. The lesion’s nature required pathological confirmation. Pathological examination confirmed low-grade differentiated carcinoma. Given the patient’s compromised pulmonary function and advanced age, surgical intervention was deemed high-risk, and conservative treatment was recommended. On August 18, 2024, the patient was transferred to the Oncology Department. Upon transfer, the diagnosis was established as follows: (I) esophageal middle thoracic cancer (T3N1M0, stage IIIB); (II) hypothyroidism. On September 18, 2024, the Oncology Department initiated IMRT targeting the positive esophageal lesion and regional lymph nodes. The prescribed dose was planning target volume (PTV)-gross tumor volume (GTV) 1.8 Gy per fraction, with 20 sessions completed. On September 21, a boost dose of PTV-GTV 2.0 Gy per fraction was administered for an additional 10 sessions, totaling 30 fractions. Immunotherapy with camrelizumab (200 mg) was delivered on October 15 and November 16, 2024. On November 18, the patient was readmitted to the Oncology Department due to symptoms of coughing, chest tightness, and dyspnea that had persisted for three days following exposure to cold weather. Physical examination revealed coarse breath sounds bilaterally and extensive wet rales in both lungs. Further laboratory and imaging investigations were conducted. The complete blood count (CBC) revealed a white blood cell (WBC) count of 9.72×10⁹/L and a neutrophil percentage (Neu%) of 96.60%, both of which were elevated compared to normal ranges. Hemoglobin (HGB) was reduced to 88.00 g/L, while the platelet count (PLT) remained within normal limits at 161.00×10⁹/L. Bacterial culture results indicated mixed growth of normal flora. A follow-up chest computed tomography (CT) performed on November 18, 2024, in comparison with the October 11, 2024, scan, demonstrated new multifocal inflammatory changes in both lungs, with consolidation noted in the right lower lobe. Treatment and subsequent re-evaluation were recommended. Additional findings included segmental atelectasis in the lingular segment of the left upper lobe and the medial segment of the right middle lobe, a calcified nodule in the posterior segment of the right upper lobe, and minimal fibrotic strands bilaterally, all of which were consistent with prior imaging.

On November 21, following a multidisciplinary consultation in our department, the patient was diagnosed with grade 3 RP combined with bacterial pneumonia. Upon transfer to our department, the patient received oxygen therapy, intravenous methylprednisolone sodium succinate (80 mg q12h) for anti-inflammatory treatment over 1–2 weeks, intravenous cefoperazone sulbactam sodium for infection control, intravenous omeprazole for gastrointestinal bleeding prophylaxis, and oral calcium carbonate D3 granules for osteoporosis prevention. By December 2, the patient’s cough and dyspnea had significantly improved, and treatment was transitioned to oral prednisone at 50 mg/day, gradually tapered to a maintenance dose. On December 3, a follow-up chest CT revealed marked resolution of bilateral pulmonary inflammation compared to the scan on November 18, with reduced consolidation in the right lower lobe. Treatment continuation and subsequent re-evaluation were recommended. Additional findings included segmental atelectasis in the lingular segment of the left upper lobe and medial segment of the right middle lobe, a calcified nodule in the posterior segment of the right upper lobe, and minimal fibrotic strands bilaterally, all consistent with prior imaging. The patient was discharged after significant improvement in cough and dyspnea symptoms.

On December 11, 2024, the patient was readmitted to the Oncology Department due to “cough and chest tightness for 2 days”. Investigations revealed that the patient had developed intermittent cough with expectoration, chest tightness, and dyspnea two days prior following exposure to cold. Physical examination demonstrated coarse breath sounds bilaterally, no dry rales heard, and fine crackles in both lungs. On December 13, bacterial culture and identification of purulent sputum showed mixed growth of normal flora with Candida albicans (2+). Respiratory pathogen nucleic acid testing for six common pathogens, tuberculosis DNA, and 2019-nCoV nucleic acid tests were all negative. Fungal markers revealed elevated Aspergillus D-glucan levels at 1,814.59 pg/mL and galactomannan at 1.02 µg/L. Bronchoalveolar lavage fluid culture on December 13 demonstrated mixed growth of normal flora with Candida albicans (+). On December 22, 2024, the routine blood test including C-reactive protein (CRP): the neutrophil count (Neu#) rose to 8.64×10⁹/L and the neutrophil percentage (Neu%) increased to 95.00%. Meanwhile, the lymphocyte count (Lym#) dropped to 0.30×10⁹/L and the lymphocyte percentage (Lym%) decreased to 3.30%. A follow-up chest CT on December 14 showed multiple bilateral pneumonia lesions compared to the scan on December 2, 2024, with progression noted. Additional findings included a calcified nodule in the posterior segment of the right upper lobe and minimal fibrotic strands bilaterally, consistent with prior imaging. The diagnosis considered: grade 3 RP combined with immune-related pneumonia and fungal infection. The patient presented primarily with exertional dyspnea, significantly impacting daily activities. A history of radiotherapy and immunotherapy within the past 3 months, along with focal consolidation signs on chest CT involving >50% of lung parenchyma, supported this diagnosis. Treatment included intravenous methylprednisolone sodium succinate (40 mg q8h) for anti-inflammatory therapy over 2 weeks and oral itraconazole (0.2 g twice daily) for antifungal treatment. By January 6, 2025, after improvement in chest tightness and dyspnea, maintenance therapy with oral prednisone (15 mg/day) was initiated until symptom stabilization. The patient regained independent toileting ability and restored daily activity capacity without supplemental oxygen, maintaining oxygen saturation around 93%. Oral corticosteroids were discontinued on February 28, 2025, following a total treatment duration of approximately 3 months. On September 26, 2025, the patient underwent a follow-up examination. The pulmonary function test report indicated mild pulmonary dysfunction, demonstrating significant improvement in pulmonary function.

The figure above illustrates the changes in chest CT images before, during, and after treatment. The image in Figure 1, dated August 5, 2024, depicts the pre-treatment condition prior to radiotherapy and immunotherapy for esophageal cancer. No patchy or ground-glass-like exudative changes were observed in either lung. On November 18, RP developed, characterized by patchy exudative shadows near the radiation field, accompanied by partial lung consolidation. Post-treatment lung imaging on December 2 revealed the resolution of patchy exudative shadows in both lungs. In Figure 2, the recurrence on December 14 is illustrated, with findings suggestive of immune-related pneumonia (10). Follow-up imaging on December 26 demonstrated attenuation of exudative shadows and partial resolution of consolidation shadows. The final re-examination on April 25 showed complete dissipation of exudative and consolidation shadows in the left lung, while residual consolidation shadows were noted in the right lung, likely attributable to infection.

Figure 1 CT images before, during, and after treatment. CT, computed tomography.

Figure 2 CT images before, during, and after treatment. CT, computed tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Diagnostic reasoning and challenges

The diagnostic process in this case was complex and evolved over time, centering on the challenge of differentiating between RP, IRP, and superimposed infections. Our clinical reasoning at each stage is detailed below.

Upon first presentation (November 2024)

The patient presented with cough, chest tightness, and dyspnea approximately 2 months after completing radiotherapy. The initial differential diagnosis included:

RP: this was the primary suspicion. The rationale was strong: (I) a clear temporal relationship, with symptoms appearing within the classic window for RP onset; (II) chest CT findings of patchy opacities and consolidation that were predominantly located within the radiation field.

Bacterial pneumonia

This was considered a co-diagnosis. Supporting evidence included: (I) acute symptomatic worsening; (II) laboratory findings of elevated WBC count (9.72×10⁹/L) and a markedly high neutrophil percentage (96.60%), which are classic markers of bacterial infection; (III) radiographic consolidation. While the sputum culture showed only mixed flora, we accounted for the well-documented low sensitivity of routine cultures. After multidisciplinary discussion, a diagnosis of grade 3 RP with suspected superimposed bacterial pneumonia was made, justifying the initiation of combined corticosteroid and empiric antibiotic therapy.

IRP: Although the patient had received immunotherapy, IRP was deemed less likely at this stage because the imaging changes were focal and aligned with the radiation port, rather than showing the diffuse or peripheral pattern often associated with IRP.

Upon re-admission (December 2024)

The recurrence of symptoms during steroid taper with new radiographic findings necessitated a critical diagnostic re-evaluation. The follow-up CT now showed progressive, bilateral ground-glass opacities with a predominantly peripheral distribution, which was a significant change from the earlier focal pattern.

This radiological evolution prompted the following reassessment:

IRP: now become the leading diagnosis. The key differentiating features from RP were: (I) the shift in radiological pattern to widespread peripheral ground-glass opacities, which is a recognized hallmark of IRP (10); and (II) the temporal association with immunotherapy, as symptoms flared within the typical risk period for IRP development.

RP flare-up

Possible, but the new diffuse and peripheral distribution was highly atypical for a pure RP exacerbation.

Fungal infection

It was seriously investigated and confirmed. The patient’s prolonged steroid use created a high risk for opportunistic infection. The positive culture for Candida albicans and elevated fungal markers (β-D-glucan) confirmed a superimposed fungal colonization or infection.

The final diagnosis for the second episode was grade 3 IRP with superimposed fungal infection. This complex picture dictated a dual therapeutic strategy: escalating corticosteroids to target the IRP while initiating antifungal therapy. This diagnostic journey underscores the critical importance of sequential radiological comparison and maintaining a high index of suspicion for IRP when a patient on checkpoint inhibitors develops new or worsening pulmonary symptoms, particularly during steroid taper.

Incidence and pathophysiology of combined pneumonitis

Radiation-induced pneumonitis is one of the most common adverse reactions following tumor treatment. This patient underwent a total of 30 radiotherapy sessions, with the first 20 sessions administered at 1.8 Gy per day and the subsequent 10 sessions at 2.0 Gy per day, resulting in a cumulative dose of 56 Gy. Additionally, the patient received two doses of camrelizumab at 200 mg each as part of immunotherapy. Extensive research indicates that the incidence of pneumonitis significantly increases when immunotherapy is combined with thoracic radiotherapy. Although this case employed fractionated radiotherapy, the total dose reached 56 Gy. According to the “Chinese Expert Consensus on the Diagnosis and Treatment of Radiation Pneumonitis”, the relationship between RP and total radiation dose is not linear; however, once a threshold dose is reached, the risk of RP markedly increases (11). Multiple studies have also demonstrated that patients receiving combined immunotherapy and thoracic radiotherapy have a higher probability of developing pneumonitis compared to those undergoing radiotherapy alone. The patient presented to our department with symptoms of “cough, chest tightness, and shortness of breath”. Given the patient’s recent history of radiotherapy and immunotherapy within the past 3 months, along with blood tests and chest CT findings upon admission, the clinical diagnosis posed a challenge. It was necessary to differentiate between infectious and non-infectious causes of pulmonary imaging changes to further explain the patient’s symptoms of cough, sputum production, and wheezing. Initial chest CT revealed multiple patchy opacities, particularly in the radiation field, prompting primary consideration of RP. Additionally, the patient exhibited symptoms of cough and sputum production, with blood tests indicating elevated WBC count and neutrophil percentage. Although sputum culture showed mixed growth of normal flora, the positive rate of sputum cultures is generally low. After multidisciplinary discussion and analysis, and in accordance with the diagnostic criteria and grading of RP, the diagnosis was established as grade 3 RP complicated by bacterial pneumonia (3,12). Treatment included corticosteroid therapy, along with anti-infective, expectorant, and bronchodilator therapies. Given the diagnosis of RP, glucocorticoid therapy is the treatment of choice; however, the timing of intervention is crucial. The pathophysiological process of RP can be divided into distinct stages:

• Acute inflammatory phase: occurring within hours to days post-radiation exposure, this phase is characterized by the release of pro-inflammatory cytokines such as TNF-α, IL-1, and IL-6;
• Latent phase: extending from several days to 3 weeks post-exposure, this period involves increased secretion in alveoli and interstitial tissues, accompanied by further release of cytokines including TNF-α, IL-1, IL-6, platelet-derived growth factor-beta (PDGF-β), and basic fibroblast growth factor (bFGF);
• Exudative phase: lasting from 3 to 12 weeks, this stage features collapse of alveolar epithelial cells and capillary endothelial cells, leading to alveolar filling with inflammatory exudates and hyaline membranes. DNA oxidative damage, microvascular thrombosis, and elevation of transforming growth factor-beta 1 (TGF-β1) levels are also observed during this period;
• Intermediary period: spanning from 12 weeks to 6 months, this phase involves dissolution of hyaline membranes, proliferation and migration of fibroblasts, and synthesis of collagen fibers;
• Fibrotic phase: initiating beyond 6 months, this stage is marked by progressive collagen deposition and fibroblast proliferation, culminating in irreversible fibrosis (13).

Two months following radiotherapy and immunotherapy, this patient exhibited pulmonary imaging changes indicative of the exudative phase. Consequently, a comprehensive treatment regimen was initiated, including intravenous methylprednisolone sodium succinate (80 mg every 12 hours) for 1–2 weeks of anti-inflammatory therapy, intravenous cefoperazone-sulbactam sodium for infection control, intravenous omeprazole for gastrointestinal bleeding prophylaxis, and oral calcium carbonate D3 granules for osteoporosis prevention. A follow-up chest CT scan after 10 days demonstrated significant resolution of bilateral pulmonary inflammation and reduction of consolidation in the right lower lobe, accompanied by marked alleviation of the patient’s dyspnea. This case underscores the critical importance of understanding pathological changes for timely corticosteroid intervention, which plays a pivotal role in preventing the progression of chronic pulmonary fibrosis. Corticosteroid therapy should adhere to the principles of early initiation, adequate dosing, and individualized management. Grade 1 RP typically requires no specific intervention, with regular monitoring and observation being the primary approach. For symptomatic grade 2 RP, oral prednisone at 0.5–1.0 mg/kg/day is recommended. Following 2–4 weeks of treatment, gradual tapering should be implemented, reducing the dose by 5–10 mg weekly or biweekly over 4–12 weeks, with initial dosage and tapering regimen adjusted according to the patient’s clinical status.

The patient was readmitted on December 11th with complaints of cough and chest tightness. A repeat chest CT revealed progression of pulmonary lesions compared to December 2nd, showing bilateral ground-glass opacities with peripheral distribution, distinct from the central distribution typically seen in RP. Considering the patient’s previous use of camrelizumab on October 15th and November 16th, with the longest interval being two months, IRP was strongly suspected, representing a significant characteristic of this case. In general, recurrence during tapering warrants investigation for potential viral or fungal infections, connective tissue diseases, or pulmonary embolism. Comprehensive investigations were conducted, including bacterial, fungal, and viral studies, repeat plasma D-dimer and connective tissue-related antigen tests, and bronchoalveolar lavage fluid culture, which revealed normal flora and Candida albicans. Given the patient’s prolonged corticosteroid use, oral itraconazole was promptly initiated for antifungal therapy. Concurrently, considering the potential IRP, the corticosteroid regimen was readjusted to the highest effective dose with appropriate extension of the tapering period. The patient received intravenous dexamethasone or methylprednisolone (equivalent to 1–4 mg/kg/day of methylprednisolone). Upon significant improvement and stabilization of respiratory symptoms (typically within 1–2 weeks), a gradual corticosteroid tapering was implemented according to an individualized protocol, reducing the dose by one-third every three days until reaching the minimum maintenance dose. Prophylactic measures for gastric ulcer prevention and calcium and vitamin D3 supplementation for osteoporosis prevention were concurrently administered. The pneumonia grading system used in this case is presented in Table 2.

Comparison with literature and novelty

Our case aligns with existing literature reporting a higher incidence and severity of pneumonitis with combined modality therapy compared to radiotherapy alone (15-18). However, it provides a rare, detailed account of the management of this overlap syndrome in an elderly patient with esophageal cancer, a population less commonly highlighted in such reports than lung cancer patients. The detailed documentation of the temporal sequence, diagnostic reasoning, and therapeutic adjustments offers a practical clinical roadmap for physicians facing similar dilemmas.

Limitations

We acknowledge several limitations inherent in this report. Firstly, as a single case report, our findings cannot be generalized, and the success of the management strategy described may not be replicable in all patients. Secondly, the diagnosis of IRP and the exclusion of infection remain presumptive to some degree, as a histopathological confirmation via lung biopsy was not performed due to the patient’s critical condition and high procedural risk. Finally, the concurrent fungal colonization introduces a confounding variable, making it difficult to isolate the precise contribution of each condition (RP, IRP, infection) to the clinical presentation.

Conclusions

In summary, with the continuous advancement of cancer treatment strategies, the incidence of adverse events such as interstitial pneumonia has also increased. Diagnosing these conditions poses significant challenges, particularly in elderly populations who often present with pre-existing chronic pulmonary comorbidities—such as chronic obstructive pulmonary disease, bronchiectasis, or old fibrotic lesions. The timing of initiating corticosteroid therapy for RP is often difficult to determine and may lead to exacerbation of pulmonary infections if not managed appropriately. In the case presented here, the patient initially developed pulmonary infiltrates in the context of prior radiotherapy, leading to a primary suspicion of RP. Corticosteroid treatment resulted in marked improvement in pulmonary function. However, during the second treatment episode, the pulmonary infiltrates worsened. In addition to considering progression of infection, IRP was also suspected, as its onset typically occurs later than that of RP. Therefore, after performing bronchoscopic lavage with metagenomic next-generation sequencing (mNGS) testing and initiating aggressive anti-infective therapy, high-dose pulse corticosteroid therapy was promptly administered. Follow-up imaging showed a reduction in pulmonary infiltrates and partial recovery of lung function. Such clinical scenarios are not uncommon, requiring physicians to make experience-based judgments regarding the appropriate timing for corticosteroid intervention. However, steroid therapy also carries the risk of opportunistic infections. Hence, the dosage and duration of corticosteroid treatment are of critical importance. This case report aims to promote the standardization and optimization of corticosteroid management in order to enhance the overall efficacy and safety of cancer therapy.

Acknowledgments

We would like to thank Editage (www.editage.cn) for English language editing.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-178/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-178/prf

Funding: This work was supported by routine departmental research funds from the authors' institution. No specific grant number is applicable.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-178/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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