Immune checkpoint blockade for patients with lung cancer and idiopathic pulmonary fibrosis

Antiprogrammed cell death-1 (PD-1) immunotherapies are a new standard of care for patients with advanced non small cell lung cancer (NSCLC) in most situations. Despite a safer toxicity profile than cytotoxic chemotherapy, some immune-related toxicity can potentially be severe, such as immune-mediated alveolar-interstitial lung disease (ILD), which occurs in 3% of treated patients. Such an immune lung reaction could lead to fatal respiratory exacerbation in case of pre-existing chronic ILD. This is the main reason why patients with pre-existing ILD have been excluded from immunotherapy clinical trials in lung cancer. Idiopathic pulmonary fibrosis (IPF) is the most frequent and severe form of ILD. Lung cancer represents a major complication of this disease; it is observed in 10–20% of patients and accounts for 10% of deaths. Optimal care is not codified, and acute exacerbations have been reported after surgery, chemotherapy and radiotherapy as well [ [1] Tzouvelekis A. Spagnolo P. Bonella F. Vancheri C. Tzilas V. Crestani B. et al. Patients with IPF and lung cancer: diagnosis and management. Lancet Respir Med. 2018; 6: 86-88https://doi.org/10.1016/S2213-2600(17)30478-2 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar ]. In Asian populations, acute exacerbation under chemotherapy occurs in 10–30% of patients [ [2] Ichihara E. Miyahara N. Maeda Y. Kiura K. Managing lung cancer with comorbid interstitial pneumonia. Intern Med. 2020; 59: 163-167https://doi.org/10.2169/internalmedicine.3481-19 Crossref PubMed Scopus (4) Google Scholar ]. Currently, few data exist concerning the safety of immunotherapy and even less concerning the impact of antifibrotic drugs in this context. We retrospectively reviewed six cases of non-Asian patients with IPF and lung cancer who were treated with a PD-1 inhibitor. Diagnoses of IPF were confirmed in multidisciplinary tumour boards based on clinical and computed tomography (CT) data, with a usual interstitial pneumonia typical pattern in four patients and a probable pattern in two patients (Fig. 1). None of the patients had clinical signs or biological tests supporting autoimmunity. The study was approved by the Institutional Review Board of the French-Learned Society for Respiratory Medicine (CEPRO number: 2020-066). Response to letter entitled: Re: Immune checkpoint blockade for patients with lung cancer and idiopathic pulmonary fibrosisEuropean Journal of CancerVol. 151PreviewWe would like to thank Ikeda et al. for their meaningful comments, which contribute to addressing the challenging clinical issue of the therapeutic management of patients with interstitial lung disease and lung cancer (LC-ILD). The authors rightly point out the higher risk of lung toxicity or acute exacerbation (AE) with immunotherapy in these patients, and as stated in our correspondence, we do not deny it. However, should all patients with LC-ILD be systematically disqualified for immunotherapy, whereas it is of major efficacy in LC? Unfortunately, we lack formal guideline on the subject, and noticeably, in a recent international survey [1], up to one- third of physicians would consider immunotherapy as a possible option in LC-ILD. Full-Text PDF Re: Immune checkpoint blockade for patients with lung cancer and idiopathic pulmonary fibrosisEuropean Journal of CancerVol. 151PreviewWe read with interest the article entitled ‘Immune checkpoint blockade for patients with lung cancer and idiopathic pulmonary fibrosis’ by Duchemann B, et al. in the March issue of the European Journal of Cancer [1]. The authors reported their experience using immune checkpoint inhibitor (ICI) in six non-small cell lung cancer (NSCLC) patients with comorbid idiopathic pulmonary fibrosis (IPF), with a typical usual interstitial pneumonia (UIP) pattern in 4 patients and a probable UIP pattern without honeycomb lung on computed tomography (CT) in 2 patients. Full-Text PDF