Pericardial effusion with pembrolizumab

Impact of bone metastasis on prognosis in non-small cell lung cancer patients treated with immune checkpoint inhibitors: a systematic review and meta-analysis

Background

Lung cancer is a leading cause of cancer-related deaths globally, with non-small cell lung cancer (NSCLC) accounting for approximately 85% of cases. While immune checkpoint inhibitors (ICIs) have transformed treatment for advanced NSCLC, the role of bone metastasis in modulating ICI efficacy remains unclear. Bone metastasis, occurring in 30-40% of advanced NSCLC cases, is associated with worse outcomes. However, how this affects the therapeutic benefit of ICIs has not been fully elucidated, highlighting a critical knowledge gap in optimizing treatment for this patient population.

Methods

A comprehensive literature search across multiple databases, including PubMed, Embase, and Cochrane, identified 13 studies with a total of 3,681 patients, of whom 37.6% had bone metastasis. Overall survival (OS) and progression-free survival (PFS) were compared between NSCLC patients with and without bone metastasis. Data were analyzed using a random-effects model to account for study heterogeneity.

Results

The meta-analysis demonstrated that bone metastasis significantly worsened overall survival (OS) and progression-free survival (PFS) in NSCLC patients treated with ICIs. Specifically, bone metastasis was associated with a 45% increased risk of death (HR: 1.45, 95% CI: 1.30-1.62, p < 0.001) and a 40% increased risk of disease progression (HR: 1.40, 95% CI: 1.25-1.58, p < 0.001). No statistically significant impact on PFS was observed. (HR: 1.28, 95% CI: 0.77-2.10, p = 0.34). High heterogeneity was observed in some subgroup analyses (I² = 72%), indicating variability in the results.

Conclusion

Bone metastasis is a significant negative prognostic factor for NSCLC patients treated with ICIs, associated with a higher risk of mortality and disease progression. These results underscore the importance of tailored treatment approaches for NSCLC patients with bone metastasis and call for further research to optimize therapy outcomes in this group.

Evaluation of time-to-onset and outcome of cardiac adverse events related to pembrolizumab using post-marketing surveillance in Japanese patients

BACKGROUND

Pembrolizumab has been widely used in patients since its release, but information on cardiac Adverse Events (AEs) related to pembrolizumab remains lacking, particularly in Japanese populations.

OBJECTIVES

This study aims to evaluate time to onset, incidence rates, and outcomes for pembrolizumab-induced cardiac AEs in patients with cancer using the Japanese Adverse Drug Event Report database.

METHODS

We analysed data for the period from April 2004 to March 2022. Data on cardiac AEs were extracted and relative risks of AEs were estimated using the reporting odds ratio.

RESULTS

We analysed 2,021,907 reports and identified 15,306 reports of AEs caused by pembrolizumab. Of these, 399 cardiac AEs were associated with pembrolizumab. Signals were detected for six cardiac AEs: myocarditis, immune-mediated myocarditis, pericardial effusion, cardiac tamponade, pericarditis, and pericarditis malignant. A histogram of median times to onset showed occurrence from 33 (21-97) days for immune-mediated myocarditis to 138 (67-168) days for pericarditis malignant, but some cases occurred even more than 1 year after the start of administration. Among these, myocarditis was the most frequently reported (27.1%), with fatal cases also reported.

CONCLUSION

This study focused on cardiac AEs caused by pembrolizumab as post-marketing AEs. Patients should be monitored not only at the time of administration, but also over time for signs of these AEs, especially myocarditis, as some patients may have serious outcomes.

Diagnosis and Management of Pembrolizumab-Associated Pericardial Effusion in a Non-small Cell Lung Cancer Patient

The advent of immune checkpoint inhibitors (ICIs) in the field of oncology has improved the outcome response rate for a variety of neoplastic pathologies with improved cellular specificity that lacks the traditional adverse effects associated with chemotherapy. However, ICIs are not without adverse associations, and a growing concern for modern clinicians is the balancing of interests that most occur to minimize these adverse effects while also improving patients' conditions from an oncologic perspective. This case presents a 69-year-old man who developed multiple episodes of significant pericardial effusion while receiving infusions of pembrolizumab for stage III-A adenocarcinoma for which he underwent a pericardiostomy procedure. Given the positive response of this immunotherapy on disease progression, the decision was made to continue the administration of pembrolizumab following the pericardiostomy with the plan of using serial echocardiography studies to monitor for the presence of clinically significant pericardial effusion in the future. In this way, the patient will still be able to receive optimal treatment for his advanced cancer while preserving adequate cardiac function.