Case report of three distinctive pulmonary toxicities related to durvalumab (PD-L1 inhibitor) consolidation therapy in locally advanced non-small cell lung cancer

Immunotherapy has become part of the standard of care in the treatment of locally advanced non-small cell lung cancer. However, immunotherapy is associated with immune-related pneumonitis and radiation-related adverse effects. Pulmonary-related toxicity after definitive chemoradiotherapy can be challenging to distinguish from disease progression, especially in the setting of additional immunotherapy after radiation. Our patient is a 61-year-old male that was diagnosed with stage IIIA lung adenocarcinoma of the right upper lobe that underwent treatment with concurrent chemoradiation and adjuvant durvalumab. He was found to have fevers, shortness of breath, generalized body aches and dry cough. His influenza test was positive for Influenza A. On imaging, there was significant hypermetabolic enlargement of multiple lymph node stations underwent bronchoscopy with biopsies of the right upper lobe, station 4R and 7 lymph node. Pathology of the right upper lobe biopsy showed fragments of bronchial epithelium with rare atypical cells present. Pathology of the station 7 lymph node showed small non-necrotizing granulomas, and station 4R showed rare atypical cells, consistent with squamous metaplasia. The patient was started on high dose prednisone for treatment of immune related pneumonitis and continue follow up in clinic. His symptoms continued to improve continued interval improvement seen on serial imaging in the right upper lobe soft tissue changes within the field of prior radiation in addition to improvement in the mediastinal and hilar lymphadenopathy, consistent with immunotherapy related Sarcoidlike granulomatous reactions. Patients treated with chemoradiation and adjuvant immunotherapy for NSCLC have unique presentations of symptoms which can be mistaken for disease progression. The interpretation of imaging of the thorax such as CT or PET/CT from these symptoms can be complicated in patients treated with immune checkpoint inhibitors therapy after radiation with acute viral infectious respiratory diseases such as influenza. The noted appearance of new lung abnormalities in patients treated with chemo-radiotherapy and immunotherapy Keywords: Non-small cell lung cancer; Immunotherapy; Pulmonary immune related adverse events; Radiation therapy. Abbreviations: AKI: Acute kidney injury; CBC: Complete blood count; cGy: Centigrey; GGOs: Ground-glass opacities; ICI: Immune checkpoint inhibitor; irAE: Immune-related adverse events; NSCLC: Non-small cell lung cancer; PCR: Polymerase chain reaction; PDL-1: Programmed death-ligand 1; PET-CT: Positron Emission Tomography–Computed Tomography; RRP: Radiation recall pneumonitis; WBC: White blood cell. # Equal contribution: Andrew Gross and Asrar Alahmadi www.jcimcr.org Page 2 Citation: Gross A, Alahmadi A, Ramaiya N, Dowlati A, Biswas T. Case report of three distinctive pulmonary toxicities related to durvalumab (PD-L1 inhibitor) consolidation therapy in locally advanced non-small cell lung cancer. J Clin Images Med Case Rep. 2021; 2(5): 1390. raises the concern of disease progression or pulmonary toxicity from treatment. Clinicians should be aware of these potential pulmonary immune-related adverse events or pseudoprogression, and a multidisciplinary team must be utilized to ensure appropriate treatment and evaluation of these complex patients.