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Immune checkpoints inhibitors, toxicity and outcome:
a case report
Teresa Beninato – Istituto Nazionale Tumori (Milano)
Immunoncology– Zurigo – 09/05/2019
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DISCLOSURE OF INTEREST
� The author declare that she has no conflict of
interest
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Background
� Male, 78 years old, ECOG PS1
� Hypertension, Diabetes Mellitus
� Diagnosed with advanced lung adenocarcinoma
� First line therapy with Pembrolizumab 200 mg flatdose d1 q21
EGFR wt, ALK and ROS1 not rearranged,
PD-L1: TPS >50%
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G4 muscular toxicity
Two weeks after starting Pembrolizumab:
Access to the Emergency Room for dyspnoea and generalized muscularhypostenia
� Arterial Blood Gas (ABG) : pH 7.35, pO2 52 mmHg, pCO2 52 mmHg
� Laboratory assessments: CPK 7175 ng / mL, CK MB 156 IU / L, Troponin T 1630 ng / ml
Rapid worsening of the respiratory failure and ABG
� CT angiography: negative for pulmonary embolism
� Echocardiography: marked septal asynchrony and infero-lateral hypo-acinesia
� Electromyography: myopathic involvement of the diaphragm
Transfer in Intensive Care Unit
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Management
Emergency management
� Tracheostomy, invasive mechanical ventilation
� High dose steroid therapy: methylprednisolone 2 mgkg IV
� Intravenous immunoglobulins (IVIG)
� Complete recovery of peripheral myopathy, partial recovery of diaphragmatic myopathy
Permanent discontinuation of immunotherapy
� No other active cancer treatments started
Eight months later…
� Impressive clinical improvement with removal of thracheostomy
� Restaging CT scan: Complete Responce after a single dose of Pembrolizumab
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Potential predictive role of irAEs
� Vitiligo & tumor response association demonstrated in
melanoma
� Increasing evidence in NSCLC:
– Skin toxicity & tumor response
– Thyroiditis & OS
– Early toxicities & OS, PFS and ORR
[Hua C et al, JAMA Dermatol 2016]
[Hasan Ali O, et al. Oncoimmunology 2016]
[Osorio JC. Et al. Ann Oncol 2016]
[Haratani K et al. JAMA Oncol 2018]
[Teraoka et al. J Tor Oncol 2017]
ESMO Preceptorship Programme
Thank you for your attention