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A4051 - Multi-System Immune-Related Adverse Effects in an Advanced Non-Small-Cell Lung Cancer Patient Treated with Pembrolizumab
Author Block: S. Rao1, L. Lin2, J. Park3, D. Ludwig4, M. ElNaggar4; 1Pulmonary/Critical Care, UC Irvine Medical Center, Orange, CA, United States, 2Family Medicine, UC Irvine Medical Center, ORANGE, CA, United States, 3Internal Medicine, UC Irvine Medical Center, ORANGE, CA, United States, 4Pulmonary/Critical Care, Long Beach VA Medical Center, Long Beach, CA, United States.
Lung cancer is the leading cause of cancer deaths in the United States. Historically, advanced non-small-cell lung cancer (NSCLC) yields poor overall survival outcomes and limited treatment options. With the promising antitumor efficacy of immune checkpoint inhibitors and the increasing use of anti-programmed death-1 antibodies in the treatment of NSCLC, novel immunotherapies are changing the practice landscape.
Our case is of a 69 year old male with a history of Stage IV NSCLC, refractory to chemotherapy who received a dose of pembrolizumab. The patient was briefly seen in the emergency room for episodes of diplopia and weakness eighteen days after receiving his infusion. A few days later the patient was admitted to the medical intensive care unit for severe weakness, hepatitis, wide-complex tachycardia refractory to treatment. Patient was initially stabilized but further investigation revealed an acute cardiomyopathy with varying arrhythmias. Additionally, from his profound weakness, he developed hypoxic and hypercapnic respiratory failure and further neurologic workup revealed full bilateral ptosis, proximal skeletal muscle weakness, and elevated anti-acetylcholine receptor antibody level suggestive of myasthenia gravis. The patient did not have any of these events prior to the initial infusion. The patient passed away seventy-seven days after receiving the infusion.
This case displays a complex case of immune related adverse events (IrAEs) that was associated with pembrolizumab. An extensive literature search revealed variable adverse events across organ systems that are associated with immunotherapy and PD1 inhibitors. While there are many case reports identifying singular adverse events, our case is one of the few with multiple organ systems affected and resultant toxicities listed above. The treatment plan led to a multidisciplinary approach and highlights the complex management and educational opportunities.
While oncology guidelines change and advocate for increased use, our literature search has indicated that not only pembrolizumab but other PD-1 inhibitors are also involved in similar adverse events. This may lead to a higher incidence of events in the future as oncology guidelines are changing and immunotherapy is becoming the standard of care. Physicians and other health care providers must become increasingly aware of these events as they will encounter a growing number of these patients. A multidisciplinary treatment and management approach with improved education and communication across all specialties will create more awareness. With the vast array of treatment options, IrAEs must be further researched and studied for clinicians to increase their knowledge of and ability to manage IrAEs.