# Optimal Corticosteroid Therapy Based on Liver Biopsy for Severe Immune-Mediated Hepatitis During Pembrolizumab Treatment: A Case Report **Authors:** Kotoba Esaki, Hideyuki Horikoshi, Maiko Awashima, Satoshi Nakayama, Yoshiko Kichikawa PMC · DOI: 10.7759/cureus.104904 · Cureus · 2026-03-09 ## TL;DR A case report shows liver biopsy can guide corticosteroid treatment for immune-related hepatitis in cancer patients. ## Contribution Demonstrates liver biopsy's role in individualizing corticosteroid dosing for immune-mediated hepatitis. ## Key findings - Liver biopsy revealed moderate lobular necroinflammation consistent with immune-mediated hepatitis. - Prednisolone at 0.3 mg/kg/day led to rapid improvement in liver enzyme levels. - ICI treatment could be safely resumed after histopathological-guided corticosteroid therapy. ## Abstract Immune checkpoint inhibitors (ICIs), including pembrolizumab, are widely used to treat advanced non-small cell lung cancer; however, they are associated with immune-related adverse events, including immune-mediated hepatitis. Although systemic corticosteroids are recommended as first-line therapy for severe immune-mediated hepatitis, the optimal initial dose remains unclear, and current guidelines specify a wide range of doses. Herein, we report the case of a 76-year-old man with lung adenocarcinoma, a history of resolved hepatitis B virus infection, ulcerative colitis in long-term remission, and latent hereditary spherocytosis who developed grade 3 immune-mediated hepatitis during pembrolizumab monotherapy. Liver biopsy revealed moderate lobular necroinflammation consistent with immune-mediated hepatitis. Based on these histopathological findings, prednisolone at 0.3 mg/kg/day was initiated. Liver enzyme levels improved rapidly, and pembrolizumab was subsequently resumed without recurrence of immune-mediated hepatitis. This case highlights the diagnostic and therapeutic value of liver biopsy in patients with severe immune-mediated hepatitis. Histopathological assessment of inflammatory severity and bile duct involvement may contribute to individualized corticosteroid dosing, promote early recovery, and support safe ICI rechallenge. ## Linked entities - **Chemicals:** prednisolone (PubChem CID 5755) - **Diseases:** lung adenocarcinoma (MONDO:0005061), hepatitis B virus infection (MONDO:0005344), ulcerative colitis (MONDO:0005101), hereditary spherocytosis (MONDO:0019350) ## Full-text entities - **Genes:** BRAF (B-Raf proto-oncogene, serine/threonine kinase) [NCBI Gene 673] {aka B-RAF1, B-raf, BRAF-1, BRAF1, NS7, RAFB1}, HP (haptoglobin) [NCBI Gene 3240] {aka HP2ALPHA2, HPA1S}, RET (ret proto-oncogene) [NCBI Gene 5979] {aka CDHF12, CDHR16, HSCR1, MEN2A, MEN2B, MTC1}, GPT (glutamic--pyruvic transaminase) [NCBI Gene 2875] {aka AAT1, ALT, ALT1, GPT1, SGPT}, PDCD1 (programmed cell death 1) [NCBI Gene 5133] {aka ADMIO4, AIMTBS, CD279, PD-1, PD1, SLEB2}, KRT20 (keratin 20) [NCBI Gene 54474] {aka CD20, CK-20, CK20, K20, KRT21}, EGFR (epidermal growth factor receptor) [NCBI Gene 1956] {aka ERBB, ERBB1, ERRP, HER1, NISBD2, NNCIS}, CD274 (CD274 molecule) [NCBI Gene 29126] {aka ADMIO5, B7-H, B7H1, PD-L1, PDCD1L1, PDCD1LG1}, CD8A (CD8 subunit alpha) [NCBI Gene 925] {aka CD8, CD8alpha, IMD116, Leu2, p32}, ROS1 (ROS proto-oncogene 1, receptor tyrosine kinase) [NCBI Gene 6098] {aka MCF3, ROS, c-ros-1}, ALK (ALK receptor tyrosine kinase) [NCBI Gene 238] {aka ALK1, CD246, NBLST3}, SLC17A5 (solute carrier family 17 member 5) [NCBI Gene 26503] {aka AST, ISSD, NSD, SD, SIALIN, SIASD} - **Diseases:** biliary stricture (MESH:D003251), metabolic dysfunction (MESH:D008659), extrahepatic bile duct dilation (MESH:D001651), non-small cell lung cancer (MESH:D002289), cholangitis (MESH:D002761), chronic hemolysis (MESH:D006461), bile duct dilation (MESH:D001649), fatty liver disease (MESH:D005234), skin rash (MESH:D005076), biliary disease (MESH:D001660), lung adenocarcinoma (MESH:D000077192), cytomegalovirus antigenemia (MESH:D003586), icterus (MESH:D007565), Immune-Mediated Hepatitis (MESH:C567355), cholecystitis (MESH:D002764), adenocarcinoma (MESH:D000230), Cancer (MESH:D009369), spherocytosis (MESH:C567159), hepatitis B virus infection (MESH:D006509), eyelid edema (MESH:D004487), acute pancreatitis (MESH:D010195), autoimmune liver diseases (MESH:D008107), hyperamylasemia (MESH:D034321), hepatic inflammation (MESH:D007249), epigastric pain (MESH:D010146), hyperbilirubinemia (MESH:D006932), primary biliary cholangitis (MESH:D008105), autoimmune hepatitis (MESH:D019693), ulcerative colitis (MESH:D003093), left renal cell carcinoma (MESH:D002292), liver tumors (MESH:D008113), infectious complications (MESH:D003141), alcohol-related liver disease (MESH:D008108), Hepatitis (MESH:D056486), hemolytic anemia (MESH:D000743), tenderness (MESH:D063806), liver injury (MESH:D017093), drug or food allergies (MESH:D004342), Granuloma (MESH:D006099), intrahepatic bile duct dilation (MESH:C531647), dilation of (MESH:D002311), irAEs (MESH:D002318), allergic rhinitis (MESH:D065631), cough (MESH:D003371), toxicity (MESH:D064420), hepatocellular (lobular) (MESH:D018275), hepatobiliary disease (MESH:D004066), Anemia (MESH:D000740), autoimmune hemolytic anemia (MESH:D000744), grade 3 immune-related hepatitis (MESH:D008224), hereditary spherocytosis (MESH:D013103), vascular thrombosis (MESH:D013927), liver metastasis (MESH:D009362), hypertension (MESH:D006973), Viral hepatitis (MESH:D014777) - **Chemicals:** bilirubin (MESH:D001663), paclitaxel (MESH:D017239), Mesalazine (MESH:D019804), oxygen (MESH:D010100), alcohol (MESH:D000438), amlodipine besylate (MESH:D017311), Ursodeoxycholic acid (MESH:D014580), steroid (MESH:D013256), Pembrolizumab (MESH:C582435), Bil (-), pemetrexed (MESH:D000068437), H&E (MESH:D006371), Prednisolone (MESH:D011239), carboplatin (MESH:D016190) - **Species:** Clostridium butyricum (species) [taxon 1492], Hepatitis B virus (no rank) [taxon 10407], hepatitis C virus [taxon 11103], human gammaherpesvirus 4 (Epstein Barr virus, no rank) [taxon 10376], Homo sapiens (human, species) [taxon 9606] ## Full text _Full body text omitted from this summary view._ Fetch the complete paper as Markdown: https://tomesphere.com/paper/PMC12969945/full.md ## Figures 5 figures with captions in the complete paper: https://tomesphere.com/paper/PMC12969945/full.md ## References 14 references — full list in the complete paper: https://tomesphere.com/paper/PMC12969945/full.md --- Source: https://tomesphere.com/paper/PMC12969945