Ranjan Niroshan, Dalati Yaman, Sabanathan Vidushan, Thangadurai Thanujan
Internal Medicine, Henry Ford Health System, Jackson, USA.
Anesthesiology, Henry Ford Hospital, Detroit, USA.
Cureus. 2025 Jun 26;17(6):e86785. doi: 10.7759/cureus.86785. eCollection 2025 Jun.
Dysphagia secondary to esophageal obstruction is a rare but clinically relevant presentation in the setting of non-small cell lung cancer (NSCLC). While pembrolizumab demonstrates efficacy in metastatic NSCLC with high programmed death-ligand 1 (PD-L1), diagnostic challenges in distinguishing pseudoprogression from true progression and paradoxical disease progression pose a clinical challenge, highlighting complexities inherent in immune checkpoint inhibitor resistance mechanisms. We present the case of an 82-year-old Caucasian woman with a diagnosis of stage IV NSCLC with extremely high PD-L1 expression who developed accelerated disease progression on pembrolizumab monotherapy. Following 11 cycles of immunotherapy, the patient developed life-threatening esophageal obstruction due to a massively enlarged subcarinal lymph node, causing significant extrinsic compression. This resulted in food impaction necessitating urgent endoscopic management, followed by aspiration pneumonia requiring medical intensive care unit admission. Endoscopic evaluation revealed a critically narrowed esophageal lumen with ulcerated and necrotic mucosa. To facilitate nutritional support and airway protection, a gastrostomy tube was inserted. This case highlights several key clinical points: mediastinal lymphadenopathy can result in life-threatening esophageal compression requiring immediate intervention; high PD-L1 expression level is no guarantee of immunotherapy efficacy and may paradoxically be associated with aggressive disease progression; tissue sampling is imperative to differentiate between true progression versus pseudoprogression; and gastrostomy tube insertion is a vital palliative intervention for malignant esophageal obstruction secondary to extrinsic compression.
非小细胞肺癌（NSCLC）患者中，继发于食管梗阻的吞咽困难虽罕见但具有临床相关性。尽管帕博利珠单抗在程序性死亡配体1（PD-L1）高表达的转移性NSCLC中显示出疗效，但区分假性进展与真性进展以及矛盾性疾病进展的诊断挑战构成了临床难题，凸显了免疫检查点抑制剂耐药机制中固有的复杂性。我们报告了一例82岁的白人女性患者，诊断为IV期NSCLC，PD-L1表达极高，接受帕博利珠单抗单药治疗后疾病进展加速。在接受11个周期的免疫治疗后，患者因隆突下淋巴结大量肿大导致危及生命的食管梗阻，造成严重的外部压迫。这导致食物嵌塞，需要紧急内镜处理，随后出现吸入性肺炎，需入住重症监护病房。内镜评估显示食管腔严重狭窄，黏膜溃疡坏死。为了便于营养支持和气道保护，插入了胃造瘘管。该病例突出了几个关键临床要点：纵隔淋巴结肿大可导致危及生命的食管压迫，需要立即干预；PD-L1高表达水平并不能保证免疫治疗有效，反而可能与侵袭性疾病进展相关；组织取样对于区分真性进展与假性进展至关重要；胃造瘘管插入是对外源性压迫继发的恶性食管梗阻进行重要姑息治疗的手段。
