Stage IVB lung adenocarcinoma with severe immune-related complications

What happened, in summary

This 72-year-old man was diagnosed with Stage IVB lung adenocarcinoma after imaging showed a right lower-lobe lung tumor with spread to the left supraclavicular fossa, left axilla, right hilum, mediastinum, abdominal para-aortic lymph nodes, and left adrenal gland. His tumor had PD-L1 expression with TPS 20% and a BRAF K601E mutation. He also had chronic obstructive pulmonary disease, hypertension, hypertrophic cardiomyopathy, and a prior history of rectal cancer surgery, making treatment decisions especially delicate. Blood counts were normal when the lung cancer was first diagnosed, which later helped clinicians recognize the blood complications as new treatment-related events.

He began combination immunotherapy with ipilimumab and nivolumab. After 1 cycle, his cancer showed a partial response, but he developed grade 3 immune-related pneumonitis. High-dose methylprednisolone followed by an oral steroid taper improved the lung inflammation, and immunotherapy was stopped. Soon after, petechiae appeared on his arms and legs, and blood tests showed severe thrombocytopenia. Steroids and platelet transfusion were not enough; he then developed severe pancytopenia, febrile neutropenia, and a markedly hypocellular bone marrow consistent with immune-related aplastic anemia.

Because his lung cancer was still responding, the care team prioritized recovery of his blood counts. Cyclosporine was attempted but stopped because of kidney toxicity. Eltrombopag was then started and escalated, leading to transfusion independence and stable counts. He remained without severe complications or cancer progression for 12 months after aplastic anemia began. After relapse, immunotherapy was not restarted. He received tegafur/gimeracil/oteracil, later developed carcinomatous meningitis, and died 20 months after his lung cancer diagnosis.