Case Report: Limbic encephalitis following treatment with durvalumab for small-cell lung cancer.

Background: Durvalumab is an immune checkpoint Inhibitor (ICIs) that is used in the treatment of malignant tumors, such as lung cancer and melanoma. ICIs are associated with immune-related adverse events including autoimmune encephalitis, although both paraneoplastic phenomena and ICI treatment may lead to autoimmunity. Case presentation: We describe a 72-year old male patient with small-cell lung cancer, who during adjuvant treatment with Durvalumab developed GABABR1 and GAD65 antibodies and both diabetes and autoimmune limbic encephalitis. Because he was followed prospectively as part of a treatment study, we had access to repeated serum samples and cognitive assessments over time prior to developing encephalitis and diabetes, in addition to later assessments. A high titer of GABABR1 antibodies appeared early, while GAD65 antibodies appeared later with a lower titer in parallel with the development of diabetes. As he subsequently developed clinical signs of encephalitis, verified by EEG and brain MRI, he also had CSF GABABR1 antibodies. Durvalumab was discontinued and steroid treatment with subsequent plasmapheresis were started, resulting in reduction of both CSF and serum antibody levels. Clinical signs of encephalitis gradually improved. Conclusion: This case illustrates the importance of being aware of possible serious autoimmune adverse reactions, including neurological syndromes such as encephalitis, when treating patients with high risk of para-neoplasia with ICIs. In addition, the case shows the development of autoantibodies over time.

Critical airway obstruction: challenges in airway management and ventilation during therapeutic bronchoscopy.

BACKGROUND: Endobronchial interventions are used to alleviate symptoms of airway stenosis. The ventilatory management may be challenging during these procedures, and may influence the choice of airway device. We report our experiences from 902 procedures. METHODS: Patients undergoing interventional bronchoscopy procedures were consecutively registered from 1999 to 2012. Critical airway obstruction (CAO) was defined as stridor, tracheal diameter <5 mm, stenosis of both the main bronchi, or clots/tumor fragments occluding the trachea or both main bronchi. Choice of airway, ventilation strategy, and survival are reported. Results are presented as median (interquartile range), and P≤0.05 was considered significant. RESULTS: A total of 561 patients underwent 902 interventional bronchoscopy procedures (mechanical debulking, laser resection, balloon dilatation, and stent placement). The procedures were performed using flexible bronchoscope through an endotracheal tube (68.2%) or laryngeal mask airway (10.4%), or by rigid bronchoscopy (9.3%). All patients were primarily ventilated by volume-controlled ventilation. CAO was classified in 60 procedures, with more frequent use of laryngeal mask airway (21.7%), and change of airway device in 20/60 procedures. The survival for patients with malignant disease with or without CAO was 100 and 182 days, respectively, with 90 days survival probability of 0.65 and 0.51 (P=0.14). CONCLUSIONS: Bronchoscopic treatment in patients with CAO may require a change of ventilatory and airway strategy during the procedure. Despite various challenges in the management of patients with CAO, the short-term survival in these patients is comparable to that in patients without CAO.

Changes in quality of life, dyspnea scores, and lung function in lung cancer patients with airway obstruction after a therapeutic bronchoscopy.

BACKGROUND: Quality of life (QoL) has been closely linked with symptom intensity in lung cancer patients. It is therefore important to relieve respiratory distress in these severely ill patients, especially because their short life expectancy. This prospective study aimed to evaluate the impact of a therapeutic bronchoscopy on QoL, dyspnea, and lung function in patients with malignant airway obstruction. METHODS: Fifteen cancer patients with airway obstruction were enrolled in the study. All patients were followed up during 2 months by 4 assessments that consisted of a clinical examination, QoL assessment using European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire with LC-13 module, Borg Dyspnea Scale, and lung function tests. RESULTS: The study showed that therapeutic bronchoscopy had a rather persistent effect on QoL and dyspnea, which were sustained for at least 2 months after the procedure. The study population had also a significant improvement in lung function. CONCLUSION: Therapeutic bronchoscopy has a positive impact on QoL, dyspnea scale values, and lung function in patients with advanced lung cancer and airway obstruction.