Pembrolizumab therapy in a patient with NSCLC and bullous pemphigoid: A case report

Abstract

Immune checkpoint inhibitor (ICI) therapy, which targets programmed cell death protein 1, has demonstrated enhanced survival outcomes in numerous patients with cancer. Historically, individuals with autoimmune diseases have been excluded from clinical trials involving cancer immunotherapies due to concerns about the potential worsening of their underlying autoimmune conditions. In the present case report, a patient with non-small cell lung cancer and bullous pemphigoid (BP) who underwent treatment with the ICI pembrolizumab is described. In this specific clinical case, no severe exacerbation of the underlying autoimmune disease was observed. Contrarily, the patient not only tolerated pembrolizumab well but also experienced amelioration of the BP lesions after the treatment. This case challenges the conventional exclusion criteria for ICI therapy in patients with autoimmune diseases, suggesting the potential safety and efficacy of such treatments in this specific population. However, further investigations and larger-scale studies are warranted to validate these findings and provide a more comprehensive understanding of the implications of ICI therapy in patients with autoimmune comorbidities.

Keywords: autoimmune diseases; bullous pemphigoid; immune checkpoint inhibitors; immunotherapy; non-small cell lung cancer; pembrolizumab.

Figure 1.

Dermal findings of the patient. (A) Multiple skin blisters were evident in November 2020. (B) Histopathological microphotograph of skin biopsy tissue from the bullous lesion shows subepidermal blisters with inflammatory cell infiltration, without prominent eosinophilic granulocytes (H&E stain; magnification, ×40). (C) Following 3 years of treatment with prednisone, the skin blisters had not healed.

Figure 2.

PET-CT and CT images of the patient at different time points. PET-CT images of the body (A) at the time of diagnosis of lung cancer and (B) after comprehensive treatment. PET-CT images of the lung (C) at the time of diagnosis and (D) after comprehensive treatment. Enhanced CT images at different angles and window levels (E) before treatment, (F) after two cycles of treatment and (G) after four cycles of treatment. Each set of images comprises three distinct panels: a upper panel, a middle panel, and a lower panel. The top panel displays coronal images of the CT mediastinal window, while the middle and bottom panels present axial images of the same slice in the lung window and mediastinal window, respectively. The images in Group E illustrate the presence of a large tumor prior to treatment, which has resulted in compression of the surrounding tissues. The images in Group F demonstrate a notable reduction in tumor volume following two cycles of treatment, accompanied by partial recovery of the lung parenchyma. The images in Group G exhibit further tumor shrinkage after four cycles of treatment, with enhanced recovery of the surrounding lung tissue and structure. PET, positron emission tomography; CT, computed tomography.

Figure 3.

Amelioration of pemphigus symptoms after treatment with pembrolizumab and chemotherapy. Skin surface blisters (A) exhibited improvement in after two cycles of treatment and (B) disappeared after four cycles of treatment.