Pneumonitis, appendicitis, and biliary obstruction during toripalimab treatment in a patient with extensive-stage small-cell lung cancer: a case report

Abstract

In recent years, immune checkpoint inhibitors (ICIs) have become a standard treatment for patients with advanced lung cancers. With the widespread use of immunotherapy in clinical practice, immunerelated adverse events (irAEs) have become increasingly common. This case report details a 72-year-old man with small-cell lung cancer (SCLC) who developed pneumonitis, appendicitis, and biliary obstruction during treatment with toripalimab. The patient was initially diagnosed with limited-stage SCLC in January 2019 and completed 5 sequential cycles of etoposide/cisplatin (EP) and radiotherapy (60 Gy/30 F). The overall response was complete response (CR) after first line treatment. He developed radiation pneumonitis after completion of radiotherapy, which responded well to symptomatic treatment. Due to newly diagnosed bone metastasis, he was administered toripalimab intravenously every 3 weeks and 12 mg anlotinib orally once a day from January 2020. By the third cycle, the patient presented with electrocardiographic abnormalities, gingival swelling and pain, and hoarseness, and consequently, the anlotinib was suspended. After 4 cycles, he developed suppurative appendicitis, which was managed successfully with anti-inflammatory agents. He then presented with shortness of breath on exertion and after a comprehensive examination, he was diagnosed with ICI-related-pneumonitis.After 6 weeks of treatment with methylprednisolone, the shortness of breath was mostly relieved and treatment continued. In June 2020, the patient developed severe vomiting. Computed tomography (CT) indicated biliary obstruction, and at endoscopic retrograde cholangiopancreatography (ERCP) there was edema of the major papilla of the duodenum. The patient's symptoms were relieved after treatment with gastric acid suppression and antiemetics. Re-examination by magnetic resonance imaging (MRI) showed that the biliary obstruction had been resolved. Although the disease progressed after immunotherapy, no tumor tissue related to the biliary obstruction was detected, and this was therefore classified as an irAE.

Uncommon Adverse Events of Immune Checkpoint Inhibitors in Small Cell Lung Cancer: A Systematic Review of Case Reports

“…Wen et al documented the initial occurrence of simultaneous pneumonitis and autoimmune DM [33]. Qu et al observed a series of adverse events, including appendicitis, biliary obstruction, and pneumonitis, manifesting sequentially in a single patient [31]. Cases of rare events not only present diagnostic challenges but also complicate treatment, as evidenced by a report by Nakai et al on colitis combining CMV infection [41].…”

Late‑onset immune checkpoint inhibitor‑related pneumonitis after cessation of sintilimab: A case report and literature review

“…CIP is one of the major causes of ICI-associated mortality (16). Symptoms of CIP include dry cough, shortness of breath with exertion, reduced oxygen saturation and bilateral ground-glass opacities or patchy nodular infiltrations in the lung on CT imaging (27,28). The incidence of pneumonia secondary to ICIs is <5%, with fatal CIP being reported in 0.2-0.5% patients (16,29).…”

Treatment of Brain Metastasis of Small Cell Lung Cancer with PD-1 Inhibitor: A Case Report

“…At present, the patient has been treated with 32 cycles of Toripalimab, during treatment tumor markers have decreased significantly, the primary and metastatic lesions have shrunk or disappeared. (Qu, Y., et al, 2021).…”