The Role of Abdominal Surgery in Refractory Immune Checkpoint Inhibitor Enterocolitis: A Case Report

Abstract

This article describes the case of a 73-year-old patient with grade 3 immune checkpoint inhibitor (ICI)-induced enteritis. Five different immunosuppressive agents (glucocorticoids, high-dose infliximab, methotrexate, mycophenolate mofetil, and vedolizumab) were administered, however, with no clinical or radiographical benefit. A laparotomy was performed, as the patient showed signs of intestinal obstruction, with a segmental resection of the ileal loop. Biopsy results showed multiple fibrotic strictures. The current treatment guidelines for ICI enterocolitis only include drugs as a treatment option. Nevertheless, it remains important to consider early surgical intervention in order to avoid serious complications due to persistent and pronounced inflammation. The current case highlights the importance of surgery as a treatment modality in the multidisciplinary approach for ICI-induced enteritis, which should be taken into consideration after second- or third-line treatment.

Keywords: Abdominal surgery; Case report; Immune checkpoint inhibitor enterocolitis; Immunotherapy; Toxicity.

Fig. 1.

Axial (a) and coronal (b) CT images with contrast: edematous wall thickening at the level of the ileal loops.

Fig. 2.

Axial (a) and coronal (b) CT images with contrast: fibrotic area with thickened loop and only minimal enhancement, no adjacent mesenteric inflammation, and prestenotic dilation.

Fig. 3.

Proposal for a management algorithm of ICI enterocolitis.