The use of immune checkpoint inhibitors in the treatment of advanced non-small cell lung cancer in a bilateral lung transplant recipient

Introduction: The use of immune checkpoint inhibitors (ICIs) in solid organ transplant (SOT) recipients remains limited and is associated with a risk of allograft rejection of 25-43% and graft loss in up to 70% of cases, particularly during the first months of treatment. Case presentation: We present the case of a 44-year-old man with an SFTPA1 gene mutation who underwent bilateral lung transplantation in 2021 due to interstitial lung disease. Examination of the explanted lungs revealed stage IIB lung adenocarcinoma, PD-L1 negative and without actionable mutations. The patient subsequently developed metastatic recurrence involving the pleura, lymph nodes, bone, and adrenal glands, and received multiple lines of systemic therapy. A sixth-line treatment with atezolizumab was initiated, achieving disease stabilization after three cycles. Subsequently, the patient developed respiratory failure, likely related to aspiration pneumonitis, which ultimately led to his death. Discussion: The use of ICIs in transplant recipients, particularly lung transplant patients, carries a high risk of allograft rejection. In this case, no evidence of acute graft rejection was observed during treatment, although available evidence remains limited. Conclusions: This case illustrates the challenges of ICI therapy in lung transplant recipients and highlights the need for individualized, multidisciplinary management.