Case report: Fatal hemoptysis after effective treatment with tislelizumab and anlotinib in pulmonary sarcomatoid carcinoma

Abstract

Pulmonary sarcomatoid carcinoma (PSC), a rare non-small cell lung cancer (NSCLC) subtype, poses diagnostic and treatment difficulties. Current research explores targeted therapies and immunotherapy to improve patient outcomes. This case report details a male patient diagnosed with PSC via pathology. Tests revealed high levels of PD-L1, a marker suggesting potential benefit from immune checkpoint inhibitors. However, despite bronchoscopic intervention, his advanced stage IIIB cancer (cT3N2bM0) progressed quickly, with progression-free survival (PFS) under 3 months. Following progression, the patient received tislelizumab (anti-PD-1 antibody) and anlotinib (an anti-angiogenic drug) as second-line therapy. This combination showed promise, achieving near-partial remission after the first cycle. Subsequent scans documented continued tumor shrinkage until the patient experienced fatal hemoptysis. This case highlights the potential benefits of combining tislelizumab with anlotinib for PSC. However, it also represents the first reported case of fatal hemoptysis with this specific treatment regimen. This finding emphasizes the need for increased awareness of this potential complication, especially in patients with centrally located PSC treated with anti-angiogenic agents like anlotinib.

Keywords: adverse effects; anlotinib; hemoptysis; pulmonary sarcomatoid carcinoma; tislelizumab.

Figure 1

Evolution of right lung target lesion on chest CT. (A) Chest enhanced CT at initial presentation (baseline). (B) After 2 cycles of chemotherapy; (C) After the last tumor resection, before starting second-line treatment (tislelizumab + anlotinib) due to recurrence of atelectasis and inability to measure the target lesion; (D) Following the first cycle of tislelizumab + anlotinib; (E) After 2 cycles of tislelizumab + anlotinib; (F) After 4 cycles of tislelizumab + anlotinib.

Figure 2

(A, B) Chest CT and bronchoscopy reveal a neoplasm obstructing the lumen of the right main bronchus; (C) Post-tumor resection bronchoscopy shows the exposure of the openings of the right middle lobe and the basal and dorsal segments of the right lower lobe, indicating the tumor primarily invaded the lumen from the right intermediate bronchus. Bronchoscopic diagnosis: mixed-type malignant central airway stenosis (V zone, VI zone) with a stenosis degree of grade 5 (91-100%); (D) Immunohistochemistry showed: tumor cells CKAE1/AE3 (+), CK8/18 (+), CK7 (+), TTF-1 (+), Vimentin (+).

Figure 3

Disease progression and treatment outcomes with multiple bronchoscopic interventions. (A) Chest CT showing right total atelectasis and mediastinal shift to the right; (B) Bronchoscopy showing complete obstruction of the right main bronchus lumen by a new growth; (C) Bronchoscopy after tumor resection showing tumor invasion of the right upper lobe; (D) Chest CT showing improvement in right atelectasis and mediastinal return to normal position after tumor resection; (E) Chest CT showing recurrence of right total atelectasis and right mediastinal displacement; (F) Bronchoscopy showing incomplete obstruction of the right main bronchus, right upper lobe bronchus by a new growth, and occlusion of the right middle bronchus; (G) Bronchoscopy after the third tumor resection; (H) Chest CT showing improvement in right atelectasis and mediastinal return to normal position after tumor resection.