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Smesseim I, Mets OM, Daniels JMA, Bahce I, Senan S. Diagnosis and management of pneumonitis following chemoradiotherapy and immunotherapy in stage III non-small cell lung cancer. Radiother Oncol 2024; 194:110147. [PMID: 38341099 DOI: 10.1016/j.radonc.2024.110147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/29/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND In inoperable stage III NSCLC, the standard of care is chemoradiotherapy and adjuvant durvalumab (IO) for 12 months. Pneumonitis is the commonest toxicity leading to discontinuation of IO. A failure to distinguish between expected radiation-induced changes, IO pneumonitis and infection can lead to unnecessary durvalumab discontinuation. We investigated the use of a structured multidisciplinary review of CT-scans, radiation dose distributions and clinical symptoms for the diagnosis of IO pneumonitis. METHODS A retrospective study was conducted at an academic medical center for patients treated for stage III NSCLC with chemoradiotherapy and adjuvant durvalumab between 2018 and 2021. An experienced thoracic radiologist reviewed baseline and follow-up chest CT-scans, systematically scored radiological features suspected for pneumonitis using a published classification system (Veiga C, Radioth Oncol 2018), and had access to screenshots of radiation dose distributions. Next, two experienced thoracic oncologists reviewed each patients' case record, CT-scans and radiation fields. A final consensus diagnosis incorporating views of expert clinicians and the radiologist was made. RESULTS Among the 45 included patients, 14/45 (31.1%) had a pneumonitis scored in patient records and durvalumab was discontinued in 11/45 cases (24.4%). Review by the radiologist led to a diagnosis of immune-related pneumonitis only in 6/45 patients (13.3%). Review by pulmonary oncologists led to a diagnosis of immune-related pneumonitis in only 4/45 patients (8.9%). In addition a suspicion of an immune-related pneumonitis was rejected in 3 separate patients (6.7%), after the thoracic oncologists had reviewed the patients' radiation fields. CONCLUSIONS In patients treated using the PACIFIC regimen, multidisciplinary assessment of CT-scans, radiation doses and patient symptoms, resulted in fewer diagnoses of immune-related pneumonitis (8.9%). Our study underscores the challenges in accurately diagnosing either IO-related or radiation pneumonitis in patients undergoing adjuvant immunotherapy after chemoradiotherapy and highlights the need for multidisciplinary review in order to avoid inappropriate cessation of adjuvant IO.
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Affiliation(s)
- I Smesseim
- Department of Thoracic Oncology, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
| | - O M Mets
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - J M A Daniels
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - I Bahce
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - S Senan
- Department of Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Shatila M, Eshaghi F, Thomas AR, Kuang AG, Shah JS, Zhao B, Naz S, Sun M, Fayle S, Jin J, Abudayyeh A, Sheshadri A, Palaskas NL, Franco-Vega MC, Gaeta MS, Thomas AS, Zhang HC, Wang Y. Practice Changes in Checkpoint Inhibitor-Induced Immune-Related Adverse Event Management at a Tertiary Care Center. Cancers (Basel) 2024; 16:369. [PMID: 38254858 PMCID: PMC10814014 DOI: 10.3390/cancers16020369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Understanding of immune-related adverse events (irAEs) has evolved rapidly, and management guidelines are continually updated. We explored temporal changes in checkpoint inhibitor-induced irAE management at a tertiary cancer care center to identify areas for improvement. We conducted a single-center retrospective study of patients who developed a gastrointestinal, pulmonary, renal, or cardiac irAE between July and 1 October in 2019 or 2021. We collected patient demographic and clinical information up to 1 year after toxicity. Endoscopic evaluation and specialty follow-up after discharge for patients with gastrointestinal irAEs declined between the 2019 and 2021 periods. Symptom duration and steroid taper attempts also declined. For pulmonary irAEs, rates of specialty consultation, hospital admission and readmission, and mortality improved in 2021 compared with 2019. Follow-up rates after hospital discharge were consistently low (<50%) in both periods. For cardiac irAEs, consultation with a cardiologist was frequent and prompt in both periods. Outpatient treatment and earlier specialty consultation improved outcomes with gastrointestinal irAEs. Our study exploring irAE practice changes over time identified areas to improve management; specifically, timely specialty consultation was associated with better outcomes for gastrointestinal irAEs. These findings can help improve the quality of management algorithms at our institution and may inform policies in other institutions.
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Affiliation(s)
- Malek Shatila
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (B.Z.); (S.N.); (A.S.T.); (H.C.Z.)
| | - Farzin Eshaghi
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX 77030, USA; (F.E.); (A.G.K.); (J.S.S.)
| | - Austin R. Thomas
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, TX 77030, USA;
| | - Andrew G. Kuang
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX 77030, USA; (F.E.); (A.G.K.); (J.S.S.)
| | - Jay S. Shah
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX 77030, USA; (F.E.); (A.G.K.); (J.S.S.)
| | - Brandon Zhao
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (B.Z.); (S.N.); (A.S.T.); (H.C.Z.)
| | - Sidra Naz
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (B.Z.); (S.N.); (A.S.T.); (H.C.Z.)
| | - Mianen Sun
- Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (S.F.)
| | - Sarah Fayle
- Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (S.F.)
| | - Jeff Jin
- Department of Informative Services, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Ala Abudayyeh
- Department of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Nicolas L. Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Maria C. Franco-Vega
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Maria S. Gaeta
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Anusha S. Thomas
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (B.Z.); (S.N.); (A.S.T.); (H.C.Z.)
| | - Hao Chi Zhang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (B.Z.); (S.N.); (A.S.T.); (H.C.Z.)
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (B.Z.); (S.N.); (A.S.T.); (H.C.Z.)
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