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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.

journal of clinical images and medical case reports

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