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Intracranial Complications From Immune Checkpoint Therapy in a Patient With NSCLC and Multiple Sclerosis: Case Report
Benjamin Y Lu1, Cigdem Isitan2,3, Amit Mahajan4
1Department of Medicine (Medical Oncology), Yale School of Medicine, New Haven, Connecticut.
Background:
Immune checkpoint inhibitors (ICIs) have become an increasingly important tool in cancer treatment, revealing durable responses in several different types of tumors, including NSCLCs. Nevertheless, ICIs carry a risk of immune-mediated toxicities. There is a paucity of data for concurrent use of these agents in patients with autoimmune disorders, such as multiple sclerosis (MS).
Case Presentation:
We report a case of a man with a history of MS and metastatic NSCLC with brain metastases who had cancer progression after receiving chemotherapy, whole-brain radiation therapy, and stereotactic radiosurgery to brain lesions and was treated with the programmed death-ligand 1 inhibitor, atezolizumab. He had dramatic clinical and radiographic benefit but developed a severe MS flare and neurologic decline precluding further treatment. Considerable growth of a previously radiated brain lesion prompted resection, with pathologic findings consistent with radiation necrosis and demyelination without viable tumor cells.
Conclusions:
Although patients with preexisting autoimmune diseases, including MS, might be at an increased risk of developing immune-related adverse events with ICIs, they may also experience anticancer benefit. Intracranial disease can be challenging to accurately diagnose in a patient with MS who previously underwent radiation, as progressing lesions can be tumor growth, MS flare, or radiation necrosis.
Insights
Immune checkpoint inhibitors (ICIs) show promise for non-small cell lung cancer (NSCLC) but may trigger autoimmune flares in patients with multiple sclerosis (MS). Careful diagnosis is crucial, as lesions can mimic tumor progression.
Area of Science:
- Oncology
- Immunology
- Neurology
Background:
- Immune checkpoint inhibitors (ICIs) offer durable responses in various cancers, including non-small cell lung cancer (NSCLC).
- ICIs are associated with immune-mediated toxicities, and data on their use in patients with autoimmune disorders like multiple sclerosis (MS) is limited.
Observation:
- A patient with a history of MS and metastatic NSCLC with brain metastases received atezolizumab (a PD-L1 inhibitor) after standard therapies failed.
- The patient experienced significant clinical and radiographic tumor response but suffered a severe MS flare and neurological decline.
Findings:
- Pathologic examination of a resected brain lesion revealed radiation necrosis and demyelination, not viable tumor cells.
- Distinguishing between tumor progression, MS flare, and radiation necrosis in the brain is challenging in patients with MS and prior radiation.
Implications:
- Patients with pre-existing autoimmune diseases, such as MS, may benefit from ICIs but face an increased risk of immune-related adverse events.
- Accurate diagnosis of intracranial lesions in MS patients with a history of radiation is critical for appropriate management.
