Perforation of small intestinal metastasis of lung adenocarcinoma treated with pembrolizumab: a case report

Abstract

BackgroundPembrolizumab is an immune checkpoint inhibitor and is an anti-human programmed cell death-1 (PD-1) monoclonal antibody. Pembrolizumab is used for non-small cell lung carcinoma with high programmed cell death ligand-1 (PD-L1) expression. It has been found that better overall survival can be obtained using pembrolizumab compared to the existing chemotherapy. We report a case of perforation of small intestinal metastasis after pembrolizumab treatment.Case presentationA 62-year-old man was treated by pembrolizumab for PD-L1 highly expressed lung adenocarcinoma, with multiple metastasis (small intestinal, lymph nodes, and bone). The treatment was stopped owing to drug-induced pneumonitis. One month after drug withdrawal, the patient visited the emergency department of our hospital with the complaint of severe stomachache. He had a rigid abdomen and generalized tenderness, and computed tomography scans showed free air within the abdomen. We diagnosed bowel perforation and performed emergency surgery. Surgical findings revealed multiple small intestine metastasis and mesenteric lymph node metastasis. Perforation was found in the metastatic site in the jejunum located around 40 cm anal to Treitz’s ligament. This perforated part was resected, and functional end-to-end anastomosis was performed using linear staplers. The post-operative course was uneventful. Pathological examination revealed lung adenocarcinoma metastasis at the perforation site, and the effectiveness of pembrolizumab was grade 1b (Japanese Classification of the Colorectal Carcinoma, seventh edition).ConclusionsThis is the first report of perforation of small intestinal metastasis of lung adenocarcinoma after pembrolizumab treatment. Because pembrolizumab causes some side effects, particularly autoimmune side effects, careful attention during treatment is warranted.

A retrospective analysis of emergency surgery for cases of acute abdomen during cancer chemotherapy. Case series

“…There have been many case reports of acute abdomen including GI perforation in patients with various kinds of cancer associated with chemotherapy [ [31] , [32] , [33] , [34] , [35] , [36] , [37] ]; however, there have been only two reports summarizing surgery cases of acute abdomen during cancer chemotherapy [ 10 , 38 ]. To our knowledge, this is the first report to clarify the risk factors for mortality after emergency surgery for acute abdomen during cancer chemotherapy.…”

Squamous Cell Carcinoma of the Tonsil Causing Small Bowel Perforation in the Setting of Metastasis and Treatment With Programmed Death-1 Inhibitors: A Case Report

“…Here we describe a case of small bowel perforation attributed to a primary SCCHN metastasizing to the GIT in the setting of treatment with PD-1 inhibitors. This is the first reported case of a palatine tonsillar cancer metastasizing to the small bowel, and adds to the small number of reported bowel perforations resulting from treatment with monoclonal PD-1 and PD-L1 inhibitors in the presence of metastatic tumor from any primary source [ 10 - 13 ].…”

Small bowel perforation and death caused by anaplastic thyroid carcinoma metastasis in a patient with concomitant colonic and bilateral breast carcinoma.

“…49,50 Rare cases of testicular seminoma, 51 osteosarcoma, 52,53 and Ewing sarcoma 54 have also been described. Symptoms of intestinal metastasis described in the literature include intussusception, 16,[20][21][22][23][24][25][26][27][28][29][43][44][45][46][47][48][49][50][51][52][53][54] and perforation [17][18][19][30][31][32][33][34][35][36][37][38][39][40][41][42] . The curative treatment of ATC is multimodal and consists of surgery and external beam radiation therapy with radio-sensitizing chemotherapy.…”