Managing Pulmonary Toxicities Associated with Immunotherapy: A Case Discussion

Abstract

Immunotherapy has changed the field of oncology around the world with the approval of immune checkpoint inhibitors for a number of tumor types over the last 5 years. However, immune‐mediated adverse events can be challenging and difficult to treat, with one of the most dire consequences being immune‐mediated pneumonitis. Key Points Rapid intervention and aggressive management for grade 3 or greater pneumonitis Slow taper of steroids and also recommend pneumocystis carinii pneumonia prophylaxis Monitor carefully for a pneumonitis flare with steroid taper, which can occur in the absence of resuming anti‐programmed cell death protein 1 (PD‐1) [1], and do not resume anti‐PD‐1 therapy until completely off steroids and no clinical or radiologic evidence of recurrence Consider observation without anti‐PD‐1 resumption—in this case, durable response was maintained even without resuming anti‐PD‐1 therapy.

Immune-Related Adverse Events in the Setting of PD-1/L1 Inhibitor Combination Therapy

“…Patients who do not respond to corticosteroids or who have recurring immune‐related colitis following a corticosteroid taper may require treatment with the antitumor necrosis factor‐α antibody infliximab. As noted above, published guidelines describing irAEs are focused on toxicity secondary to CTLA‐4 and PD‐1/L1 monotherapies or to the concurrent administration of both types of ICIs. Since co‐administration of another type of therapy (e.g., chemotherapy with a PD‐1/L1 inhibitor) may confound the diagnosis of immune‐related colitis and lead to the delay of a suitable remedy, current immunotherapy management guidelines should be applied judiciously.…”

“…Although further study is needed, recent reports highlight the potential detrimental effect on anticancer response of high‐dose steroids at the onset or during PD‐1/L1 inhibitor treatment and thus the need to continue to refine treatment algorithms for irAEs based on available evidence. Similar to the approach used for PD‐1/L1 inhibitor monotherapy , the diagnosis and management of irAEs in patients receiving combination therapy will require an integrated team of oncologists and specialists.…”

“…Whereas mild irAEs can generally be treated supportively, severe toxicity requires urgent intervention and, in some cases, may be fatal . The recognition that irAEs may arise in patients receiving PD‐1/L1 inhibitors has prompted the coordination of multidisciplinary groups to scrutinize these toxicities and the development of consensus guidelines by professional organizations to diagnose and manage them .…”

Pulmonary adverse events due to immune checkpoint inhibitors: A literature review

“…Nonspecific interstitial pneumonitis (NSIP) and diffuse alveolar damage (DAD) are additional patterns of lung toxicity associated with cancer immunotherapy [34][35][36][37][38][39]41]. Nonspecific interstitial pneumonitis is a rare ILD.…”

“…Other reported histological and radiological patterns are "diffuse alveolar hemorrhage (DAH)'' [8,[42][43], "hypersensitivity pneumonitis (HP)'' [8,34,36], "acute interstitial pneumonitis (AIP)'' [8,[36][37][38], "acute respiratory distress syndrome (ARDS)'' [8,39], "pulmonary fibrosis (PF)'' [8,[48][49] and radiation recall pneumonitis [50][51].…”