Would you continue pembrolizumab in an asymptomatic metastatic NSCLC patient with high PD-L1, who develops granulomatous mediastinal lymphadenopathy biopsy proven as sarcoid?

Sarcoid-like granulomatous reactions have been described with checkpoint inhibitors. It is important to diagnose them when they occur, in order to not confuse these findings with disease progression, especially in a patient with lung cancer. I have had two patients at least show growing mediastinal lymphadenopathy and on biopsy were diagnosed by my pulmonary colleagues to have sarcoid-like reactions. As far as I know, there are no guidelines to manage these when they occur specifically due to checkpoint inhibitors.

As always, common sense should prevail. If a patient is asymptomatic, I monitor, avoid steroids, and continue the checkpoint inhibitor. If there are symptoms such as shortness of breath, cough, fatigue (no other explanation or et...