Durvalumab-related interstitial pneumonia

Case contributed by Dr Fabien Ho

Presentation

Bronchial carcinoma PD-L1+ in the right upper lobe treated with radiotherapy and chemotherapy then with immunotherapy (durvalumab).

Patient Data

Age: 50 years
Gender: Male

Onset: 6 months after initiation of durvalumab

CT

Bilateral GGO forming circles, creating the "reversed halo" or "atoll" signs suggesting an organizing pneumonia pattern.

The bronchial carcinoma was located in the upper segment of the right upper lobe.

1 month later

CT

GGO with similar OP pattern, non migratory, but fading compared to previous CT.

3 months later

CT

Emerging peripheral subpleural reticulations and GGO, asymmetrically, with left predominance, and traction bronchiectasis.

In some areas, there is a subpleural thin line of spared lung parenchyma typical of the fibrotic NSIP pattern.

Case Discussion

This is a case of immune checkpoint inhibitor therapy-related pneumonitis with durvalumab, an anti-PD-L1 binding human monoclonal antibody, which allows T lymphocyte activation and cytotoxic function towards tumors expressing PD-L1 surface protein.

At the onset of the pneumonitis, the atoll / reversed halo signs were highly suggestive of organized pneumonia pattern. BAL was not performed although it would have been advised to do so to rule out mucormycosis-related pneumonia, which also features atoll / reversed halo signs.
Upon follow-up, the patient developed an NSIP pattern.

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