Lung Cancer: Fellow Case Report Poster - Lung Cancer |

Nivolumab-Induced Pneumonitis FREE TO VIEW

Karan Chugh, MD; Karan Jatwani, MBBS; Ravinder Bhanot, MD; Basim Dubaybo, MD
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Wayne State University, Rochester, MI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):678A. doi:10.1016/j.chest.2016.08.773
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SESSION TITLE: Fellow Case Report Poster - Lung Cancer

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Recent approval of programmed cell death-1 inhibitors for non-small cell lung cancer (NSCLC) has rapidly led to their widespread use. Pneumonitis has been recognized as a rare(1-3%) life-threatening adverse event1; however clinical & radiological manifestations remain yet to be described. We describe a case with development of nivolumab-induced pneumonitis in 12 weeks of initiation.

CASE PRESENTATION: 65-year-old male with COPD(not on home oxygen O2) & stage IIA NSCLC underwent chemo-radiation therapy with remission for 2 years. During PET/CT surveillance, bilateral hilar FDG-avid masses were noted & sub-carinal lymph node fine needle aspiration was consistent with atypical cells suspicious for reoccurrence. Nivolumab was started. After 5 cycles of Nivolumab patient developed hypoxia(SaO2 72% on room air) with diffuse ground glass infiltrates & consolidative changes. Prednisone taper over 6-weeks was initiated & he was discharged home on 2L O2. Nivolumab was restarted after 4 weeks. Patient again presented with profound hypoxia(SaO2 60% on room air), requiring 4L O2, had right pleural effusion, required draining & repeat course of prednisone. Introducing Nivolumab 3rd time was thought to be detrimental & patient was offered gemcitabine instead, for recurrence.

DISCUSSION: Nivolumab therapy is well tolerated, with 14% of patients experiencing grade 3-4 treatment-related adverse events2. Treatment-related deaths in patients with NSCLC were all associated with pneumonitis2. Pneumonitis onset has been reported within 7.4 to 24.3 months with varied radiological presentation from ground-glass or reticular opacities, consolidations, cryptogenic organizing pneumonia to pleural effusions3. In our patient, pneumonitis developed within 3 months of initiation, improved with steroids & developed again when drug was resumed with fatal adverse event & subsequent progression of cancer on its discontinuation.

CONCLUSIONS: With the increasing use of immunotherapy, awareness of the radiographic and clinical manifestations of adverse events is very critical for the prompt diagnosis & management. Currently, existing literature supports steroids as treatment option, delaying nivolumab for grade 2 & discontinuation of immunotherapy for grade 3 & 4 pneumonitis2. However, when to resume treatment after first episode of pneumonitis, total steroids duration & whether to make switch to other PD-1 inhibitors remains unclear.

Reference #1:J Natl Compr Canc Netw 2016;14(3):255-264

Reference #2: J Clin Oncol 33:2004-2012

Reference #3: N Engl J Med 2015; 373:1627-1639

DISCLOSURE: The following authors have nothing to disclose: Karan Chugh, Karan Jatwani, Ravinder Bhanot, Basim Dubaybo

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