case_images: PMC8545816_01
case_images: Gastric tissue sections from a patient with metastatic gastric cancer and rare severe immune-related cholestatic hepatitis and subsequent severe late-onset pneumonia after pembrolizumab therapy. Representative photomicrographs show H&E staining (A,B) and immunohistochemical staining with programmed death-ligand 1 (PD-L1) (C,D), using a PDL1 antibody (DACO, 22C3).
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case_images: F1
case_images: HER-2 expression (Figure 1). He was diagnosed with metastatic gastric cancer with multiple abdominal cavity lymph node and peritoneal metastases (HER2 negative, pMMR, and PD-L1
case_images: The timeline of diagnosis, treatment and related immune-side effects of this patient since diagnosis.
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case_images: F2
case_images: Given his high PD-L1 CPS and the significant overall survival (OS) improvement in patients with CPS >= 10 treated with pembrolizumab compared to those with chemotherapy in the KEYNOTE-062 trail, he was recommended and administered with 100 mg pembrolizumab as the first-line chemotherapy every 2 weeks for 5 cycles (Figure 2). ECOG PS of 1, and bilirubin levels were within normal limits (Table 1). Enhanced CT of the abdominopelvic cavity showed that PR was maintained (Figure 2) with progression-free survival (PFS) of 7 months.
case_images: Reprensentative images of magnetic resonance cholangiopancreatography (A,B) and abdominal computed tomography (C) in a patient with metastatic gastric cancer and rare severe immune-related cholestatic hepatitis and subsequent severe late-onset pneumonia after pembrolizumab therapy. No obvious biliary obstruction was observed.
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case_images: F3
case_images: Neither magnetic resonance cholangiopancreatography (MRCP) nor abdominal computed tomography (CT) showed significant biliary obstruction or bile duct dilatation (Figure 3).
case_images: Immune-related pneumonitis in a patient with metastatic gastric cancer and rare severe immune-related cholestatic hepatitis and subsequent severe late-onset pneumonia after pembrolizumab therapy. Baseline chest computed tomography (CT) images show the lungs before starting immunotherapy (A1-A4). Follow-up axial CT images obtained 4 months after administering the pembrolizumab therapy showing non-specific interstitial pneumonia (B1-B4). Immunotherapy was halted, and steroid therapy was administered. Follow-up chest CT images show near complete resolution of pneumonitis (C1-C4). Chest CT images obtained after the steroid therapy was discontinued for 5 weeks (D1-D4).
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case_images: F4
case_images: Another chest CT showed interstitial changes, and interstitial pneumonia was considered probable (Figure 4). Symptoms improved 6 days later, and resolution of the interstitial lung changes was seen on CT (Figure 4).