Recurrent pleural effusions and cardiac tamponade as possible manifestations of pseudoprogression associated with nivolumab therapy- a report of two cases

[Advances in Pseudoprogression of Immune Checkpoint Inhibitors in Non-small Cell Lung Cancer]

The advent of immune checkpoint inhibitors (ICIs) has greatly improved the prognosis of advanced lung cancer patients, but can lead to pseudoprogression (PsP), which complicates clinical evaluation and management. PsP is manifested as temporary enlargement of the tumour or the appearance of new lesions, etc., and improvement in imaging occurs with continued treatment, mostly without worsening of clinical symptoms. Currently, there are still difficulties in the early diagnosis of PsP, and its occurrence mechanism is not yet clear, lacking good predictive factors and related biomarkers. This article reviews the current research status of PsP of ICIs in non-small cell lung cancer in order to provide helpful clinical strategies for oncologists using these drugs.
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Immune Checkpoint Inhibitors and Their Cardiovascular Adverse Effects

Immune checkpoint inhibitors (ICIs) have reshaped and have become a well-established treatment modality for multiple advanced-stage malignancies. ICIs block the immune system regulatory checkpoints, namely CTLA-4 and PD-1/PDL1, which provokes excess immune response against self-antigens. Immune modulation with ICIs can result in diverse immune-related adverse events targeting organ systems. Several cases of ICI-related cardiotoxicity were reported, while the actual incidence was likely underestimated due to heterogeneous clinical presentation. These include, but are not limited to, myocarditis, pericarditis, atherosclerosis, and arrhythmia. EKG, Troponin, Echocardiogram (TTE), and Cardiac MRI (CMRI) are indispensable diagnostic tools to aid in the management of cardiac adverse effects. Herein, we review the ICI-mediated cardiovascular adverse events, diagnosis, treatment strategies, and reintroduction of ICIs post-cardiotoxicity.

Cardiac tamponade during pembrolizumab treatment in a patient with ovarian cancer: a case report

We present the case of a 39-year-old woman with platinum-resistant ovarian cancer who was treated with pembrolizumab. After five cycles of pembrolizumab treatment, she suddenly developed cardiac tamponade with a pleural effusion. The malignant pericardial and pleural effusion had increased, while the other malignant lesions had diminished in size. After pericardial and pleural drainage, no re-accumulation occurred. Pembrolizumab was continued and the patient did not have tumor progression for > 20 months. In some patients with pembrolizumab-induced cardiac tamponade, continuation of pembrolizumab treatment may be possible if other lesions decrease in size and the pericardial effusion can be controlled after drainage.

Immune checkpoint inhibitors related respiratory disorders in patients with lung cancer: A meta-analysis of randomized controlled trials

Background

In recent years, immune checkpoint inhibitors (ICIs) had extremely rapid growth in anti-cancer and improved outcomes of many malignancies, specifically lung cancer. However, the incidence of ICIs-related adverse events also raised. Using this meta-analysis, ICIs-related respiratory disorders were investigated in lung cancer patients.

Methods

Using Cochrane Library, Embase, and PubMed databases, we performed an integrated search for randomized controlled trials (RCTs) to compare respiratory disorders among different regimens. The data was prepared with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, and the quality of included studies was evaluated based on the Cochrane manual.

Results

In total, 22 RCTs were involved in this meta-analysis. Compared with ICIs, chemotherapy reduced the risk of interstitial lung disease (p = 0.03; SMD: 2.81; 95% CI: 1.08, 7.27), pleural effusion (p = 0.002; SMD: 2.12; 95% CI: 1.32, 3.42), and pneumonitis (p < 0.00001; SMD: 9.23; 95% CI: 4.57, 18.64). ICIs plus chemotherapy could provide a higher probability for patients to suffer pneumonitis than chemotherapy (p = 0.01; SMD: 1.96; 95% CI: 1.17, 3.28). In addition, single ICI brought a lower likelihood for patients suffering pneumonitis than double ICIs (p = 0.004; SMD: 2.17; 95% CI: 1.27, 3.69).

Conclusion

ICIs-based treatment, such as ICIs alone, ICIs plus chemotherapy and double ICIs, can raise the incidences of some respiratory disorders in patients with lung cancer. It suggests that ICIs should be conducted based on a comprehensive consideration to prevent ICIs-related respiratory disorders. To a certain degree, this study might be provided to the clinician as a reference for ICIs practice.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022378901, identifier (CRD42022378901).

Immune-related generalised oedema - A new category of adverse events with immune checkpoint inhibitors

BACKGROUND

Generalised oedema was occasionally reported associated with immune checkpoint inhibitors (ICPIs). The purpose of this study is to investigate immune-related generalised oedema (ir-GE) drug related to ICPI, through frequency, clinical and pathological characteristics, and patient's outcome.

PATIENTS AND METHODS

Objectives of the study were to report on ir-GE associated with ICPI to define frequency, associated signs and symptoms, pathological characteristics, severity, and response to corticosteroids. To be included in the study, adult patients had to have ir-GE related to ICPI with certain or likely link, without any other known causes of generalised oedema. The study design was observational, over the period 2014-2020, from pharmacovigilance databases in France, including the prospective Registre des Effets Indésirables Sévères des Anticorps Monoclonaux Immunomodulateurs en Cancérologie (REISAMIC) registry. Calculation of the frequency of ir-GE was restricted to the prospective REISAMIC registry.

RESULTS

Over 6633 screened patients, 20 had ir-GE confirmed drug related to ICPI. Based on the prospective REISAMIC registry, the frequency of ir-GE was 0.19% of ICPI-treated patients (3 cases out of 1598 screened patients). The 20 patients with ir-GE had a median (range) age of 62 (26-81) years, most frequent tumour types were melanoma (n = 9; 45%) and lung cancer (n = 6; 30%). The most frequent localisations of oedema were peripheral (n = 17; 85%), pleural (n = 13; 65%), and peritoneal (n = 10; 50%). Polyserositis was observed in 11 (55%) patients. The median (range) weight gain per patient was 9 (2-30) kg. Associated signs and symptoms met criteria for capillary leak syndrome (n = 4; 20%), sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) (n = 3; 15%), or subcutaneous autoimmune syndrome (n = 2; 10%). Corticosteroids were administered to 15 patients; of them, 10 (67%) improved clinically after corticosteroids. Based on CTCAEV5.0, the highest severity of ir-GE was grade ≥4 in 11 (55%) patients and four (20%) patients died due to ir-GE.

CONCLUSIONS

Generalised immune system-related oedema is a new category of adverse event with immune checkpoint inhibitors and is often associated with a life-threatening condition. The pathophysiology may in some cases be related to endothelial dysfunctions, such as SOS/VOD or capillary leak syndrome.

Cardiotoxicity induced by immune checkpoint inhibitor: The complete insight into mechanisms, monitoring, diagnosis, and treatment

Immune checkpoint inhibitors (ICIs) have been taking cancer research by storm as they provide valuable therapeutic benefits to cancer patients in terms of immunotherapy. Melanoma and non-small cell lung cancer (NSCLC) are among the most prevalent cancer varieties that were utilized in ICI trials with many other cancer types being involved too. Despite impressive clinical benefits of overall response rate (ORR), progression-free survival (PFS), etc., ICIs are also accompanied by various immune-related adverse events (irAEs). Amongst the irAEs, cardiotoxicity bags a crucial role. It is of paramount importance that ICI-induced cardiotoxicity should be studied in detail due to its high mortality rate although the prevalence rate is low. Patients with ICI cardiotoxicity can have a greatly enhanced life quality despite adverse reactions from ICI therapy if diagnosed early and treated in time. As such, this review serves to provide a complete insight into the predisposing factors, mechanism, diagnostic methods and treatment plans revolving around ICI-induced cardiotoxicity.

Checkpoint-inhibitor induced Polyserositis with Edema

Background

As immune checkpoint inhibitors (ICI) are increasingly being used due to effectiveness in various tumor entities, rare side effects occur more frequently. Pericardial effusion has been reported in patients with advanced non-small cell lung cancer (NSCLC) after or under treatment with immune checkpoint inhibitors. However, knowledge about serositis and edemas induced by checkpoint inhibitors in other tumor entities is scarce.

Methods and results

Four cases with sudden onset of checkpoint inhibitor induced serositis (irSerositis) are presented including one patient with metastatic cervical cancer, two with metastatic melanoma and one with non-small cell lung cancer (NSCLC). In all cases treatment with steroids was successful in the beginning, but did not lead to complete recovery of the patients. All patients required multiple punctures. Three of the patients presented with additional peripheral edema; in one patient only the lower extremities were affected, whereas the entire body, even face and eyelids were involved in the other patients. In all patients serositis was accompanied by other immune-related adverse events (irAEs).

Conclusion

ICI-induced serositis and effusions are complex to diagnose and treat and might be underdiagnosed. For differentiation from malignant serositis pathology of the punctured fluid can be helpful (lymphocytes vs. malignant cells). Identifying irSerositis as early as possible is essential since steroids can improve symptoms.

Would the Addition of Immunotherapy Impact the Prognosis of Patients With Malignant Pericardial Effusion?

Pericardial effusion is a common finding in advanced-stage lung cancer. The presence of malignant cells or drainage of exudate effusion in the pericardial space may cause symptoms of dyspnea, pleuritic chest pain, and syncope. In addition to the difficulty physicians face in the detection and diagnosis of malignant pericardial effusion, treatment may be challenging considering the cancer prognosis and cardiovascular stability of the patient. Despite the availability of several treatment modalities for malignant pericardial effusion, including chemotherapy and surgery, patients with lung cancer historically present with poor prognoses. In addition to lung adenocarcinoma with malignant pericardial effusion, this case was complicated by COVID-19 and malignancy-associated obstructive pneumonia. We present a case of a 64-year-old woman with advanced non-small cell lung carcinoma (NSCLC) with malignant pericardial effusion who, despite testing positive for COVID-19 and having obstructive pneumonia, had favorable outcomes following systemic therapy with combined chemo-immunotherapy.

Exploring the Mechanisms Underlying the Cardiotoxic Effects of Immune Checkpoint Inhibitor Therapies

Adaptive immune response modulation has taken a central position in cancer therapy in recent decades. Treatment with immune checkpoint inhibitors (ICIs) is now indicated in many cancer types with exceptional results. The two major inhibitory pathways involved are cytotoxic T-lymphocyte-associated protein 4 (CTLA4) and programmed cell death protein 1 (PD-1). Unfortunately, immune activation is not tumor-specific, and as a result, most patients will experience some form of adverse reaction. Most immune-related adverse events (IRAEs) involve the skin and gastrointestinal (GI) tract; however, any organ can be involved. Cardiotoxicity ranges from arrhythmias to life-threatening myocarditis with very high mortality rates. To date, most treatments of ICI cardiotoxicity include immune suppression, which is also not cardiac-specific and may result in hampering of tumor clearance. Understanding the mechanisms behind immune activation in the heart is crucial for the development of specific treatments. Histological data and other models have shown mainly CD4 and CD8 infiltration during ICI-induced cardiotoxicity. Inhibition of CTLA4 seems to result in the proliferation of more diverse T0cell populations, some of which with autoantigen recognition. Inhibition of PD-1 interaction with PD ligand 1/2 (PD-L1/PD-L2) results in release from inhibition of exhausted self-recognizing T cells. However, CTLA4, PD-1, and their ligands are expressed on a wide range of cells, indicating a much more intricate mechanism. This is further complicated by the identification of multiple co-stimulatory and co-inhibitory signals, as well as the association of myocarditis with antibody-driven myasthenia gravis and myositis IRAEs. In this review, we focus on the recent advances in unraveling the complexity of the mechanisms driving ICI cardiotoxicity and discuss novel therapeutic strategies for directly targeting specific underlying mechanisms to reduce IRAEs and improve outcomes.

Review of Immune-Related Adverse Events (irAEs) in Non-Small-Cell Lung Cancer (NSCLC)—Their Incidence, Management, Multiorgan irAEs, and Rechallenge

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced malignancies, including non-small cell lung cancer (NSCLC). These agents have improved clinical outcomes and have become quite an attractive alternative alone or combined with other treatments. Although ICIs are tolerated better, they also lead to unique toxicities, termed immune-related adverse events (irAEs). A reconstituted immune system may lead to dysregulation in normal immune self-tolerance and cause inflammatory side effects (irAEs). Although any organ system can be affected, immune-related adverse events most commonly involve the gastrointestinal tract, endocrine glands, skin, and liver. They can occur anytime during the treatment course and rarely even after completion. Owen and colleagues showed that approximately 30% of patients with NSCLC treated with ICIs develop irAEs. Kichenadasse et al. conducted a thorough evaluation of multiorgan irAEs, which is of particular interest because information regarding these types of irAEs is currently sparse. It is important to delineate between infectious etiologies and symptom progression during the management of irAEs. Close consultation with disease-specific subspecialties is encouraged. Corticosteroids are the mainstay of treatment of most irAEs. Early intervention with corticosteroids is crucial in the general management of immune-mediated toxicity. Grade 1–2 irAEs can be closely monitored; hypothyroidism and other endocrine irAEs may be treated with hormone supplementation without the need for corticosteroid therapy. Moderate- to high-dose steroids and other additional immunosuppressants such as tocilizumab and cyclophosphamide might be required in severe, grade 3–4 cases. Recently, increasing research on irAEs after immunotherapy rechallenge has garnered much attention. Dolladille and colleagues assessed the safety in patients with cancer who resumed therapy with the same ICIs and found that rechallenge was associated with about 25–30% of the same irAEs experienced previously (4). However, such data should be carefully considered. Further pooled analyses may be required before we conclude about ICIs’ safety in rechallenge.

Pericardial effusion with pembrolizumab

INTRODUCTION

The treatment of non-small cell lung cancer (NSCLC) has profoundly changed on account of the arrival of new therapies, like immunotherapy. Within this group of drugs, those aimed at the programmed cell death-1 or programmed cell death ligand-1(PD1/PDL-1) are very relevant, for example, Pembrolizumab. Although its adverse reactions are generally mild and well tolerated, it has been associated with certain immune-related adverse events (IrAEs) than can be serious and affect any organ.

CASE REPORT

A 62-year-old woman diagnosed with stage IV NSCLC with a single bone metastasis and PD-L1 expression of 60% started treatment with cisplatin-pemetrexed-pembrolizumab, and maintenance with pembrolizumab.

MANAGEMENT AND OUTCOME

The patient attended the ER with pericardial effusion that was assumed to be a Pembrolizumab IrAE and was managed with corticosteroids. The patient fully recovered but immunotherapy was not reintroduced due to the severity of the AE.

DISCUSSION

The cardiovascular system is among the least affected organs by immunotoxicity, with an incidence between 0.09-0.6%. However, some authors suspect the incidence is underestimated. Median time to onset is highly variable, ranging from 6 weeks since the first dose to 2 years after discontinuation of the treatment. There are not guidelines on the most effective management of the IrAEs, but according to the pharmaceutical reference, corticosteroids should be initiated followed by a progressive reduction. If no response is obtained, another immunosuppressive agent should be added. The determination to restart immunotherapy depends on the severity of the adverse reaction, the availability of other alternative treatments, and the cancer response.

Pulmonary Toxicities of Immunotherapy

Immune checkpoint inhibitors are a form of immunotherapy that are increasingly being used in a wide variety of cancers. Immune-related adverse events (irAEs) pose a major challenge in the treatment of cancer patients. Pneumonitis, the most common lung irAE, can cause significant disruptions in the treatment of cancer and may be life-threatening. The goal of this chapter is to instruct readers on the incidence and clinical manifestations of pneumonitis and to offer guidance in the evaluation and treatment of patients with pneumonitis.

Response criteria for immunotherapy and the radiologic patterns of immune-related adverse events

Immunotherapy has revolutionized clinical outcomes in both early-stage and advanced-stage malignancies. Immunotherapy has improved patient survival in both solid and hematologic disorders with the potential added benefit of less toxicity compared to conventional cytotoxic chemotherapy. Imaging plays a fundamental role in monitoring treatment response and assessment of immune-related adverse events, e.g. pneumonitis, colitis, etc. Familiarity with the current strategies of immune-related response evaluation and their limitations is essential for radiologists to guide clinicians with their treatment decisions. Radiologists should be aware of the wide spectrum of immune-related adverse events and their various radiological features as well as the patterns of treatment response associated with immunotherapies.

Pseudoprogression in lung cancer patients treated with immunotherapy

Lung cancer has attracted much attention because of its high morbidity and mortality worldwide. The advent of immunotherapy approaches, especially the application of immune checkpoint inhibitors (ICIs) has dramatically changed the treatment of lung cancer, but a novel and unexpected pattern of treatment response-- pseudoprogression, has been observed simultaneously which complicates the routine clinical evaluation and management. However, manifestations of pseudoprogression vary and there are many disputes on immune-related response assessment and corresponding treatments for lung cancer. Therefore, we summarized the possible mechanisms, clinical manifestations and corresponding treatment measures of pseudoprogression in lung cancer, as well as potential methods to differentiate pseudoprogression from true tumor progression.

Late-onset Pleural and Pericardial Effusion as Immune-related Adverse Events after 94 Cycles of Nivolumab

A 67-year-old man with primary lung adenocarcinoma was hospitalized due to massive bilateral pleural effusion and pericardial effusion after 94 cycles of nivolumab therapy. We were unable to identify the cause of these effusions using blood tests, cytology tests, or bacterial culture of pleural effusion and thoracoscopy. Finally, we administrated corticosteroids, which immediately improved the fluid accumulation. This case may support the introduction of corticosteroids for late-onset pleural and pericardial effusion during immune checkpoint inhibitor (ICI) treatment. However, the safety of rechallenge of ICIs after the improvement of fluid accumulation is controversial.

Pulmonary Toxicities Associated With the Use of Immune Checkpoint Inhibitors: An Update From the Immuno-Oncology Subgroup of the Neutropenia, Infection & Myelosuppression Study Group of the Multinational Association for Supportive Care in Cancer

The development of immune checkpoint inhibitors (ICIs) has revolutionized cancer treatment, with agents such as nivolumab, pembrolizumab, and cemiplimab targeting programmed cell death protein-1 (PD-1) and durvalumab, avelumab, and atezolizumab targeting PD-ligand 1 (PD-L1). Ipilimumab targets cytotoxic T lymphocyte-associated antigen-4 (CTLA-4). These inhibitors have shown remarkable efficacy in melanoma, lung cancer, urothelial cancer, and a variety of solid tumors, either as single agents or in combination with other anticancer modalities. Additional indications are continuing to evolve. Checkpoint inhibitors are associated with less toxicity when compared to chemotherapy. These agents enhance the antitumor immune response and produce side- effects known as immune-related adverse events (irAEs). Although the incidence of immune checkpoint inhibitor pneumonitis (ICI-Pneumonitis) is relatively low, this complication is likely to cause the delay or cessation of immunotherapy and, in severe cases, may be associated with treatment-related mortality. The primary mechanism of ICI-Pneumonitis remains unclear, but it is believed to be associated with the immune dysregulation caused by ICIs. The development of irAEs may be related to increased T cell activity against cross-antigens expressed in tumor and normal tissues. Treatment with ICIs is associated with an increased number of activated alveolar T cells and reduced activity of the anti-inflammatory Treg phenotype, leading to dysregulation of T cell activity. This review discusses the pathogenesis of alveolar pneumonitis and the incidence, diagnosis, and clinical management of pulmonary toxicity, as well as the pulmonary complications of ICIs, either as monotherapy or in combination with other anticancer modalities, such as thoracic radiotherapy.

Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: A Systematic Review

Simple Summary

This review article addresses the toxic effects on the heart associated with the use of certain cancer-treating drugs known as immune checkpoint inhibitors. These drugs target specific proteins in the cell cycle that are abundantly expressed in cancerous cells; however, they inadvertently damage non-cancerous tissue. In the heart, this occurs in the form of dysfunction or death of smooth muscle cells, leading to consequences such as infection, heart rhythm changes, and hormonally dependent and independent ischemia. This review examines the average and median onset of these drug toxicities as well as antidotes. One key observation is that these side effects are positively skewed, meaning they occur early in cancer treatment.

Abstract

Immune checkpoint inhibitors are immune stimulatory drugs used to treat many types of cancer. These drugs are antibodies against inhibitory proteins, such as CTLA-4 and PD-1/PD-L1, that are expressed on immune cells. When bound, they allow for increased stimulation of T cells to fight tumor cells. However, immune checkpoint inhibitors have several immune-related adverse effects. Many cases have come to light recently of cardiotoxicity as a result of treatment with these drugs. Cardiotoxicity from immune checkpoint inhibitors is unique due to its rarity and high mortality rate. Patients with this toxicity may present with myocarditis, pericarditis, Takotsubo cardiomyopathy, conduction disorders, and others within just a few weeks of starting immune checkpoint inhibitors. We present here a review of the current research on immune checkpoint inhibitors, their associated cardiotoxicities, the timing of presentation of these conditions, lab tests and histology for each condition, and finally the treatment of patients with cardiotoxicity. We observe a positive skew in the onset of presentation, which is significant for the treating physician.

Pulmonary adverse events due to immune checkpoint inhibitors: A literature review

Cancer immunotherapy aims to stimulate the immune system to fight against tumors, utilizing the presentation of molecules on the surface of the malignant cells that can be recognized by the antibodies of the immune system. Immune checkpoint inhibitors, a type of cancer immunotherapy, are broadly used in different types of cancer, improving patients' survival and quality of life. However, treatment with these agents causes immune-related toxicities affecting many organs. The most frequent pulmonary adverse event is pneumonitis representing a non-infective inflammation localized to the interstitium and alveoli. Other lung toxicities include airway disease, pulmonary vasculitis, sarcoid-like reactions, infections, pleural effusions, pulmonary nodules, diaphragm myositis and allergic bronchopulmonary aspergillosis. This review aims to summarize these pulmonary adverse events, underlining the significance of an optimal expeditious diagnosis and management.

Chronic Pleuritis and Recurrent Pleural Effusion After Atezolizumab for Small Cell Lung Cancer

Patient: Female, 65-year-old

Final Diagnosis: Pleural effusion • small cell lung cancer

Symptoms: Shortness of breath

Medication:—

Clinical Procedure: —

Specialty: Pulmonology

Progressive Pleural Effusion as an Immune-Related Adverse Event in NSCLC: A Case Report

Immune checkpoint inhibitors (ICIs) have improved the clinical outcome of NSCLC. However, immune-related adverse events (irAEs) such as pneumonitis, thyroiditis, and colitis have been reported with the increasing use of ICIs. The diagnosis of irAEs relies on exclusion. With proper management, most patients may still benefit from ICI treatment. Pleural effusion is a rare presentation of an irAE. Here, we report a patient who experienced progressive bilateral pleural effusions during the first-line treatment of cisplatin, pemetrexed, and pembrolizumab. Serial study and surgical pleural biopsy found the possible cause of irAE. His pleural effusion subsided after discontinuing therapy. IrAE may present as pleural effusion and physicians should be alert to unknown causes of pleural effusion in patients under ICI treatment.

Successful Re-administration of Atezolizumab for a Non-small-cell Lung Cancer Patient after Cardiac Tamponade Development as a Manifestation of Pseudo-progression Induced by Combination Treatment with Atezolizumab and Cytotoxic Chemotherapy

Pseudo-progression is a phenomenon induced by treatment with immune checkpoint inhibitors and is characterized by an increase in tumor size or the appearance of new lesions, followed by tumor regression. However, life-threatening conditions, such as cardiac tamponade, can develop in such patients. We herein report on a 69-year-old man with lung adenocarcinoma who developed cardiac tamponade as a manifestation of pseudo-progression induced by treatment with atezolizumab combined with cytotoxic chemotherapy. After managing the cardiac tamponade, atezolizumab was successfully re-administered along with cytotoxic chemotherapy without disease progression.

Cardiac Toxicities Associated with Immune Checkpoints Inhibitors: Mechanisms, Manifestations and Management

Immune checkpoint inhibitor (ICI) associated cardiovascular adverse events (CVAE) have become more frequent with the growing use of cancer immunotherapy. CVAEs include a wide spectrum of diseases such as myocarditis, pericarditis, heart failure, arrhythmias, coronary artery disease, and hypertension. The induction of cardiovascular side effects by ICI use is hypothesized to occur due to inflammation and immune dysregulation of normal tissue in response to immunotherapy. Management of ICI-associated CVAEs mitigates an overactive immune response by utilizing steroids, immunomodulatory drugs and hemodynamic stabilization. However, few controlled studies on the cardiovascular safety of ICIs exist and treatment of their side effects are mostly from limited case series. Our review seeks to provide the most recent understanding of ICI-associated CVAEs and their management.

Higher CD4/CD8 ratio of pleural effusion predicts better survival for lung cancer patients receiving immune checkpoint inhibitors

Pleural effusion is a rare immune-related adverse event for lung cancer patients receiving immune checkpoint inhibitors (ICIs). We enrolled 281 lung cancer patients treated with ICIs and 17 were analyzed. We categorized the formation of pleural effusion into 3 patterns: type 1, rapid and massive; type 2, slow and indolent; and type 3, with disease progression. CD4/CD8 ratio of 1.93 was selected as the cutoff threshold to predict survival. Most patients of types 1 and 2 effusions possessed pleural effusion with CD4/CD8 ratios ≥ 1.93. The median OS time in type 1, 2, and 3 patients were not reached, 24.8, and 2.6 months, respectively. The median PFS time in type 1, 2, and 3 patients were 35.5, 30.2, and 1.4 months, respectively. The median OS for the group with pleural effusion CD4/CD8 ≥ 1.93 and < 1.93 were not reached and 2.6 months. The median PFS of those with pleural effusion CD4/CD8 ≥ 1.93 and < 1.93 were 18.4 and 1.2 months. In conclusion, patients with type 1 and 2 effusion patterns had better survival than those with type 3. Type 1 might be interpreted as pseudoprogression of malignant pleural effusion. CD4/CD8 ratio ≥ 1.93 in pleural effusion is a good predicting factor for PFS.

Mechanisms and clinical manifestations of cardiovascular toxicities associated with immune checkpoint inhibitors

Immunotherapies have greatly expanded the armamentarium of cancer-directed therapies in the past decade, allowing the immune system to recognize and fight cancer. Immune checkpoint inhibitors (ICIs), in particular, have revolutionized cancer treatment and have demonstrated survival benefit in numerous types of cancer. These monoclonal antibodies increase anti-cancer immunity by blocking down-regulators of adaptive immunity, including cytotoxic T lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), and its ligand (PD-L1), resulting in anti-tumor activity. As ICIs increase immune system activation, they can cause a wide range of inflammatory side effects, termed immune-released adverse events. Though these toxicities can affect nearly any organ, the most fatal toxicity is myocarditis. Here, we discuss the diverse spectrum of cardiovascular toxicities associated with ICI use. In addition, we provide insight and future directions on mechanisms and treatments for immune-related adverse events (irAEs) involving the myocardium, pericardium, vasculature, and conduction system.

Safety profile of drugs for advanced melanoma: A report based on 2008-2018 US Food and Drug Administration Data

We describe the safety profiles of all drug classes used for the treatment of advanced melanoma from the US Food and Drug Administration Adverse Event Reporting System over 2008-2018. Adverse reactions reported in 25 900 pharmacovigilance cases are described for chemotherapies, immunomodulators, targeted therapies and immunotherapies. There was a sharp increase in the number of cases over time, with peaks associated with the launch of new treatments. The adverse reactions diversified over time; notably, skin (alopecias, dermatitis) and retinal disorders were frequently associated with targeted therapies and endocrine disorders (hypothalamus, thyroid and adrenal dysfunctions) with immunotherapies. Less well-known reactions were also detected, such as neuropsychiatric disorders with targeted therapies and gastrointestinal ulcers, pneumothorax and pleural effusions with immunotherapies. The findings highlight the need for various health professionals (including medical specialists or trained nurses) to enhance management of complications.

Immune Checkpoint Inhibitors and Cardiac Toxicity in Patients Treated for Non-Small Lung Cancer: A Review

Lung cancer is a major cause of cancer-related mortality worldwide, both in men and women. The vast majority of patients are diagnosed with non-small-cell lung cancer (NSCLC, 80-85% of lung cancer cases). Therapeutics named immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment in the last decade. They are monoclonal antibodies, and those directed against PD-1 (programmed cell death protein 1) or PD-L1 (programmed cell death-ligand 1) have been used in the treatment of lung cancer and significantly improved the prognosis of NSCLC patients. However, during treatment with ICIs, immune-related adverse events (irAEs) can occur in any organ and any tissue. At the same time, although cardiac irAEs are relatively rare compared to irAEs in other organs, they have a high mortality rate. The two most common clinical manifestations of immunotherapy-related cardiotoxicity are myocarditis and pericarditis. Various types of arrhythmias have been reported in patients treated with ICIs, including the occurrence of life-threatening complete atrioventricular block or ventricular tachyarrhythmias. Here, we aim to summarize the incidence, clinical manifestations, underlying mechanisms, diagnosis, and treatment strategies for ICI-associated cardiotoxicity as these issues become very important in view of the increasing use of ICI in the treatment of lung cancer.

Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of immune-related adverse events: pulmonary toxicity

The immune checkpoints associated with the CTLA-4 and PD-1 pathways are critical modulators of immune activation. These pathways dampen the immune response by providing brakes on activated T cells, thereby ensuring more uniform and controlled immune reactions and avoiding immune hyper-responsiveness and autoimmunity. Cancer cells often exploit these regulatory controls through a variety of immune subversion mechanisms, which facilitate immune escape and tumor survival. Immune checkpoint inhibitors (ICI) effectively block negative regulatory signals, thereby augmenting immune attack and tumor killing. This process is a double-edged sword in which release of regulatory controls is felt to be responsible for both the therapeutic efficacy of ICI therapy and the driver of immune-related adverse events (IrAEs). These adverse immune reactions are common, typically low-grade and may affect virtually every organ system. In the early clinical trials, lung IrAEs were rarely described. However, with ever-expanding clinical applications and more complex ICI-containing regimens, lung events, in particular, pneumonitis, have become increasingly recognized. ICI-related lung injury is clinically distinct from other types of lung toxicity and may lead to death in advanced stage disease. Thus, knowledge regarding the key characteristics and optimal treatment of lung-IrAEs is critical to good outcomes. This review provides an overview of lung-IrAEs, including risk factors and epidemiology, as well as clinical, radiologic, and histopathologic features of ICI-related lung injury. Management principles for ICI-related lung injury, including current consensus on steroid refractory pneumonitis and the use of other immune modulating agents in this setting are also highlighted.

Cardiovascular Complications of Systemic Therapy in Non-Small-Cell Lung Cancer

Cardiovascular diseases may determine therapy outcomes of non-small-cell lung cancer (NSCLC). The evidence for how iatrogenic cardiovascular complications contribute to ceasing anticancer treatment, decreasing the quality of life or even premature death, is unclear. Older patients and smokers are at risk of atherosclerosis and arterial thromboembolic events (TE), such as myocardial infarction or stroke. Venous TE can be observed in up to 15% of NSCLC patients, but the risk increases three to five times in ALK (anaplastic lymphoma kinase)-rearranged NSCLC. ALK inhibitors are associated with electrophysiological disorders. Cytotoxic agents and anti-VEGF inhibitors mainly cause vascular complications, including venous or arterial TE. Cardiac dysfunction and arrhythmias seem to be less frequent. Chemotherapy is often administered in two-drug regimens. Clinical events can be triggered by different mechanisms. Among epidermal growth factor inhibitors, erlotinib and gefitinib can lead to coronary artery events; however, afatinib and osimertinib can be associated with the development of heart failure. During anti-PD1/anti-PDL1 therapy, myocarditis is possible, which must be differentiated from acute coronary syndrome and heart failure. Awareness of all possible cardiovascular complications in NSCLC encourages vigilance in early diagnostics and treatment.

Monitoring efficacy of checkpoint inhibitor therapy in patients with non-small-cell lung cancer

Aim: Radiological criteria alone do not reflect the entire population benefitting from checkpoint inhibitor therapy (CIT). This study aimed to detect patterns to assess CIT efficacy in non-small-cell lung cancer (NSCLC) patients. Materials & methods: We evaluated clinical, radiological and laboratory parameters in a retrospective cohort of NSCLC patients treated with nivolumab. Results: A total of 51 patients were included in the analysis. Most single parameters failed to reflect treatment benefit. Three laboratory parameters (lactate dehydrogenase, C-reactive protein and the neutrophil/lymphocyte ratio) combined in a weighted score could predict benefit with a sensitivity of 92.3% and a hazard ratio of 0.31 (95% CI: 0.16-0.59) in an early phase of therapy. Sorting patients by score showed a 1-year survival of 36% in those predicted as not benefitting versus 68% in those predicted to benefit. Conclusion: A weighted score integrating common serum markers could help detect patients benefitting from checkpoint inhibitors during ongoing CIT.

Deep and Prolonged Response to Aurora A Kinase Inhibitor and Subsequently to Nivolumab in MYCL1-Driven Small-Cell Lung Cancer: Case Report and Literature Review

Small-cell lung carcinoma (SCLC) is one of the most aggressive solid tumors, and the prognosis has not improved significantly in 25 years. Despite a recent understanding of the genomic aberrations seen in SCLC, these insights have not led to any breakthroughs in treatment. We present a patient with SCLC harboring a novel MYCL1 fusion protein who experienced a prolonged disease course due to the use of Aurora A kinase inhibitor and subsequently nivolumab. MYC family genes are master regulators of several cellular pathways including proliferation, differentiation, and apoptosis and recently have been shown to be involved in tumor immune evasion. Large studies have shown that a significant proportion of patients with SCLC have amplification or overexpression of MYC family genes. Preclinical data have exposed vulnerability of MYC-driven tumors to Aurora kinase inhibitors, bromodomain and extraterminal domain inhibitors, and recently to immune checkpoint blockers. Further studies using these agents with selective enrolling of patients with MYC-altered tumors are warranted to exploit these vulnerabilities.

Cardiotoxicity of FDA-approved immune checkpoint inhibitors: A rare but serious adverse event

Refractory cancer represents a challenge for oncologists in providing treatment options without excessive toxicity and has led to the investigation of immune mechanisms. Immune checkpoint inhibitors (ICIs) directly interfere with the tumor cells' ability to evade the innate and adaptive immune system by targeting specific proteins such as cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), programmed cell death protein-1 (PD-1), and programmed cell death protein-ligand 1 (PD-L1), which are involved as negative regulators of T-cell function. Their growing success has led to the investigation for frontline treatment in several types of cancers. Even though these ICIs have demonstrated efficacy in the treatment of a variety of cancers, their use has been associated with the development of rare but severe adverse events. These events are the result of targeting specific checkpoint proteins on normal cells of the body as well as secondary downstream off-target effects on normal tissue. Similar to combined conventional cancer treatment, treating with combined ICIs are also associated with a higher risk of adverse events. Although cardiotoxicities related to immunotherapy are reportedly rare, they can be severe and associated with life-threatening conditions such as fulminant heart failure, hemodynamic instability, and cardiac arrest. Oncologists must carefully weigh the risk versus the therapeutic benefit of these agents in determining the best option for improving overall survival and minimizing morbidity and mortality of their patients. Our review focuses on the approved ICIs, their mechanism of action, their oncologic efficacy, and the associated potential for cardiovascular toxicity.

Pericardial tamponade during pembrolizumab treatment in a patient with advanced lung adenocarcinoma: A case report and review of the literature

Several studies have demonstrated increased pericardial effusion during anti-PD-1 immunotherapy, and treatment in patients who have developed pericardial tamponade is controversial. In this study, we describe a 63-year-old woman with stage IVA lung adenocarcinoma given pembrolizumab as a first-line therapy. After four cycles of pembrolizumab treatment, the patient suddenly developed a pericardial tamponade. Although pericardial effusion was increased, her tumor lesions were reduced. After an emergency pericardiocentesis, she continued the pembrolizumab therapy without recurrent pericardial effusions for three months until the primary tumor and lymph node metastasis progressed. Nine months after the pericardiocentesis, the patient died of progressive lung cancer, but pericardial effusion did not recur throughout the treatment course. This case study suggests that pembrolizumab therapy can be continued with a strict follow-up in some patients with pembrolizumab-induced pericardial tamponade. KEY POINTS: • Significant findings of the study Our patient developed pericardial tamponade during pembrolizumab treatment but continued pembrolizumab treatment after emergency pericardiocentesis without recurrent pericardial effusions. • What this study adds Pembrolizumab treatments may be resumed with a strict follow-up in some patients with treatment-related pericardial tamponade.

Patterns of response in metastatic NSCLC during PD-1 or PD-L1 inhibitor therapy: Comparison of the RECIST 1.1 and iRECIST criteria

Background

Immunotherapy plays an important role in advanced non‐small cell lung cancer (NSCLC). However, radiological evaluation is challenging due to the potential inflammatory effects of immunotherapy, which can lead to atypical response patterns. Identifying these atypical responses is critical to making treatment decisions and prognostication.

Methods

We performed a retrospective analysis of consecutive advanced NSCLC patients treated with immunotherapy (alone or in combination). We collected patients' clinical and pathological data, analyzed the proportion of patients who continued immunotherapy beyond progressive disease (PD) per RECIST 1.1, and compared the differences in response patterns between the RECIST 1.1 and iRECIST criteria.

Results

A total of 43 patients treated at the Peking Union Medical College, China from January 2018 to April 2019 were included. Continued immunotherapy beyond PD per RECIST 1.1 was observed in 10 (33.3%, 10/30) patients, of which there were discordant assessments (30%, 3/10) between the RECIST 1.1 and iRECIST, which were evaluated as PD by RECIST 1.1 and immune unconfirmed PD by iRECIST. Among seven patients with immune confirmed PD, one (1/30, 3.3%) had pseudoprogression. Patients who continued immunotherapy beyond PD (n = 10) experienced significantly prolonged overall survival (not reached vs. 8.1 months: hazard ratio, 2.8; 95% confidence interval: 2.7–13.6, P = 0.03) compared with patients who did not continue immunotherapy beyond PD (n = 20).

Conclusions

RECIST 1.1 evaluation underestimated the benefit of immunotherapy. Further research is required to optimize iRECIST and establish some criteria for selecting patients who will benefit from continued immunotherapy beyond PD per RECIST 1.1.

Immune-Related Adverse Events: Pneumonitis

Checkpoint inhibitors are part of the family of immunotherapies and are increasingly being used in a wide variety of cancers. Immune-related adverse events pose a major challenge in the treatment of cancer patients. Pneumonitis is a rare immune-related adverse event that presents in distinct patterns. The goal of this chapter is to instruct readers on the incidence and clinical manifestations of pneumonitis and to offer guidance in the evaluation and treatment of patients with pneumonitis.

Cancer Treatment-Related Lung Injury

Lung injury associated with cancer therapeutics is often the limiting factor that trumps otherwise successful cancer therapy. Thoracic radiation as well as cancer pharmacotherapeutics, including conventional chemotherapy, molecular targeted agents, and cancer immunotherapies, have been associated with a unique spectrum of histopathologic injury patterns that may involve the lung parenchyma, pleura, airways, and/or pulmonary vasculature. Injury patterns may be idiosyncratic, unpredictable, and highly variable from one agent class to the next. Variability in lung injury patterns within a specific therapeutic class of drugs also occurs, adding to the conundrum. Drug-induced toxicities to the thoracic cavity are infrequent, and early recognition of clinical clues portends a good outcome in most cases. Failure to recognize early clinical signs, however, may result in irreversible and potentially lethal consequences.

This chapter provides an overview of our current knowledge of thoracic complications associated with cancer pharmacotherapies. The review is not intended to be a treatise of all cancer agents that adversely affect the lungs, but rather a discussion of established risk factors and histopathologic patterns of lung injury associated with broad classes of cancer agents. Optimal management strategies, based on existing clinical experience, will also be discussed. Complications associated with thoracic radiation are also reviewed. It is hoped that these discussions will facilitate early recognition and management of treatment-related thoracic complications and, ultimately, better patient outcomes.

Cardiac tamponade in a patient with stage IV lung adenocarcinoma treated with pembrolizumab

Immunotherapy drugs are associated with a multitude of immune-related adverse events. We describe a case of cardiac tamponade in a patient with stage IV lung adenocarcinoma, with almost 100% expression of PDL-1, treated with pembrolizumab. The patient is a 62-year-old male who developed worsening shortness of breath after five cycles of pembrolizumab. He was diagnosed with large pericardial effusion on computed tomography chest. Echocardiogram confirmed tamponade physiology. He was treated with discontinuation of pembrolizumab and urgent pericardial window followed by high dose prednisone with tapering. The patient responded very well to the treatment. We have comprehensively reviewed cases of pericardial effusion secondary to either immune mediated mechanisms or pseudoprogression.

Pericardial effusion under nivolumab: case-reports and review of the literature

Background

Nivolumab, a programmed death-1 (PD-1) inhibitor, is an immune checkpoint inhibitor particularly used in the treatment of malignant melanoma, non-small cell lung cancer and renal cell carcinoma. Immune-related adverse events are frequent under immunotherapies. Cardiotoxic side effects, initially thought to be rare, are more often encountered paralleling the expanding use of immune checkpoint blockade. Among them, pericardial effusion and tamponade deserve attention as they may present with unusual symptomatology.

Case presentation

We report three cases of pericardial effusion under nivolumab for lung adenocarcinoma. Two cases of early and late-onset pericardial effusion were symptomatic with tamponade and one case occurred without any symptoms. Pericardiocentesis with pericardial biopsy was performed in symptomatic pericardial effusion followed by the administration of a corticotherapy. Pericardial biopsies showed infiltration of T-lymphocytes, mostly CD4⁺. Nivolumab was stopped in two cases and resumed for one patient. Pericardial effusion evolved positively in all cases with or without treatment.

Conclusions

We review the literature on pericardial effusion under nivolumab to further discuss the hallmarks of pericardial effusion under nivolumab and the management of nivolumab therapy in this situation. In conclusion, pericardial effusion as an immune-related adverse event under nivolumab appears less rare than initially thought and may require particular attention.

Immune-mediated Pericarditis With Pericardial Tamponade During Nivolumab Therapy

A 69-year-old man with metastatic lung adenocarcinoma presented with pericarditis and pericardial tamponade during nivolumab treatment, despite near-complete response on images performed during response evaluation. Further investigation found no evidence of pericardial or pleural cancer involvement, and pathologic evaluation showed immune-related adverse effect. Surgical and steroid treatments were used, with excellent results, and no disease progression on follow-up despite drug discontinuation because of toxicity. Although life-threatening immune-related adverse effects are not frequent when using checkpoint inhibitors, and cardiotoxicity is very rare, different clinical manifestations may occur, and some of them can be fatal in case of inadequate management. It may be challenging to make an etiological diagnosis; however, favorable outcomes can be achieved when prompt directed treatment is promoted.

Cardiac Immune-Related Adverse Events in Immune Checkpoint Inhibition Therapy

Immune checkpoint inhibitors present clinicians with both an exciting step forward in cancer treatment and the unknown possibilities of an unshackled immune system. The latter phenomena, known as immune-related adverse events (irAEs), are of particular interest because they may affect any organ system with autoimmune-like pathologies, such as hepatitis and colitis. Within the cardiovascular system, irAEs associated with immune checkpoint blockade exist as a broad clinical spectrum, with autoimmune myocarditis being the best-characterized entity at this time. In general, irAEs are often reversible with immunosuppression. However, irAEs that affect the cardiovascular system pose the possibility of a rapid and fatal clinical deterioration. The mortality attributed to immune checkpoint blockade-associated autoimmune myocarditis, as reported in the WHO database, exists from 36% to 67%, dependent on the therapeutic regimen. Yet, despite the potential severity such events pose, guidelines dictating the identification of immune checkpoint inhibition irAEs do not exist, providing a stark contrast with other anticancer medications with known cardiovascular effects. The lack of guidelines may be related to the perceived rarity of these events, yet a recent study of immune checkpoint inhibition-associated autoimmune myocarditis suggests that this clinical entity may be more prevalent than initially believed. Until more standardized information regarding these potentially serious events is available, the study of documented cases is instructive to improve identification of such phenomena, as well as the outcomes for patients who develop them.

Targeted Cancer Therapies With Pericardial Effusions Requiring Pericardiocentesis Focusing on Immune Checkpoint Inhibitors

Case reports have reported immune checkpoint inhibitors (ICI), especially nivolumab, are associated with recurrent pericardial effusions. Our objective was to determine how often patients being treated with ICI develop hemodynamically significant pericardial effusion requiring pericardiocentesis compared with other cancer therapeutics and whether the survival of patients who underwent pericardiocentesis differs according to ICI use versus standard cancer therapeutics. Our institutional review board approved catheterization laboratory data collection for all pericardiocenteses performed and all patients receiving ICI from January 1, 2015 to December 31, 2017. Retrospective review of the electronic medical record was performed to identify cancer therapeutics given preceding pericardiocentesis. Log-rank analysis was performed to compare survival in patients requiring pericardiocentesis between those on ICI and those not on ICI. Overall, 3,966 patients received ICI of which only 15 pericardiocenteses were required, including 1 repeat pericardiocentesis in a patient on nivolumab. The prevalence of pericardiocentesis among patients on ICI was 0.38% (15/3,966). Eleven pericardiocenteses were performed after nivolumab infusion, 3 after pembrolizumab, and 1 after atezolizumab, with pericardiocentesis prevalences for each agent of 0.61% (11/1,798), 0.19% (3/1,560), and 0.32% (1/309), respectively. One hundred and twenty pericardiocentesis were performed on patients receiving other cancer therapeutics although no therapeutic agent was associated with more pericardiocenteses than nivolumab. In conclusion, the prevalence of hemodynamically significant pericardial effusions and ICI administration is uncommon, and survival durations after pericardiocentesis for patients receiving ICI and those not receiving ICI are similar, suggesting that frequent echocardiographic monitoring for pericardial effusions is not necessary.

Are we ready to describe response or progression to immunotherapy in lung cancer?

Immune checkpoint inhibitors have changed history and management of different tumor types, including non-small cell lung cancer (NSCLC). Response patterns may be more heterogeneous than those seen with cytotoxic chemotherapy. Besides atypical response patterns, new types of outcome should be taken into account such as pseudo-progression (PP) and hyper-progressive disease (HPD). PP is described as initial tumor increase or appearance of new lesions followed by their shrinkage during immunotherapy treatment while HPD is a rapid and severe pattern of progression with a not yet univocal definition. Physiopathology and underlying mechanism of these phenomena are not completely understood and in absence of reliable clinical and biological markers of response to immunotherapy, radiological evaluation remains a key point in clinicians' decision-making process but further efforts would be useful to identify a unique system of evaluation.In this review we summarize the main radiological criteria available in the evaluation of response to checkpoint inhibitors and we describe peculiar response patterns such PP and HPD with a focus on lung cancer.

Management of cardiac tamponade during nivolumab of lung cancer with intrapericardial bleomycin: case report

Immuno-checkpoint inhibitor response and immune-related adverse events remain controversial issues. Managing pericardial effusion during programmed cell death 1 inhibitor treatment is challenging. Here, we report a case of successfully managed cardiac tamponade caused by nivolumab-induced pseudoprogression. A 62-year-old male diagnosed with advanced lung adenocarcinoma started on nivolumab. Seven days later, he experienced cardiac tamponade and required pericardiocentesis, and other lesions were larger on computed tomography. The patient’s condition stabilized after pericardiocentesis. However, although the lesions other than pericardial effusion were reduced on chest CT, cardiac tamponade recurred after 6 weeks. We considered that the case involved cardiac tamponade induced by pseudoprogression and administered intrapericardial bleomycin after pericardiocentesis. Thereafter, the patient was administered nivolumab for 7 months until disease progression.

Non-parallel anti-tumour effects of pembrolizumab: a case of cardial tamponade

We present the case of a 70-year-old man with stage IV lung adenocarcinoma. He was treated with pembrolizumab, a programmed cell death-1 (PD-1) inhibitor, as a first-line therapy. After six cycles of pembrolizumab, he suddenly developed cardiac tamponade. With the exception of newly massive malignant pericardial effusion, the other malignant lesions improved. Pembrolizumab was continued and the patient has shown a durable response for two years. This is the unique case of late-onset pericaridial effusion with pembrolizumab, showed discrepant anti-tumour effects. A proper assessment is crucial to ensure favourable clinical outcomes in patients treated with PD-1 inhibitor.

Curative effect assessment of immunotherapy for non-small cell lung cancer: The "blind area" of Immune Response Evaluation Criteria in Solid Tumors (iRECIST)

Immunotherapy has considerably changed the treatment of lung cancer. As immunotherapy has a special mechanism of action, the disease remission that it can induce is unique. Recently, Immune Response Evaluation Criteria in Solid Tumors (iRECIST), which focus on assessing the apparent curative effect of immunotherapy, have become widely accepted. Based on iRECIST criteria, if the response to immunotherapy is determined to be immunity‐confirmed progressive disease or immunity‐unconfirmed progressive disease, and the Eastern Cooperative Oncology Group score is worse than before treatment, immunotherapy should be discontinued. We report two immunity‐confirmed progressive disease cases after pembrolizumab treatment and one immunity‐unconfirmed progressive disease case after nivolumab treatment. All three patients benefited from continued immunotherapy, which indicates that the iRECIST criteria may have limitations in assessing the efficacy of immunotherapy for non‐small cell lung cancer patients.

Pericardial Effusion With Tamponade in Lung Cancer Patients During Treatment With Nivolumab: A Report of Two Cases

Background: Nivolumab is an immune checkpoint inhibitor (ICI) that has shown efficacy for treating non-small cell lung cancer and has become a standard therapy for previously treated non-small cell lung cancer. Moreover, immune-related adverse events of ICI therapy are well-known. Malignant pericardial effusions occasionally arise in patients with lung cancer. There have been a few reports of pericardial effusion in non-small cell lung cancer after nivolumab administration. However, the cause of this condition is controversial; the possibilities include serositis as an immune-related adverse event or pseudo-progression.

Case Presentation: This report presents two cases of pericardial effusion with tamponade in lung cancer during treatment with nivolumab. Both patients experienced temporal increases in pericardial effusions followed by effusion regression. In one case, nivolumab administration was continued after performance of pericardiocentesis, without an increase in pericardial effusion. In the other case, temporal simultaneous increases in both the pericardial effusion and the primary tumor were detected, followed by simultaneous regression in both the effusion and the tumor. These findings support the fact that the pericardial effusions were caused by pseudo-progression.

Conclusions: Pericardial effusion with tamponade can occur in lung cancer patients being treated with nivolumab; moreover, some of these effusions might be caused by pseudo-progression. In the case of putative pseudo-progression, continuation of nivolumab administration might be allowable with strict follow up.

Pericardial effusion due to pembrolizumab-induced immunotoxicity: A case report and literature review

The advent of immune checkpoint inhibitors has revolutionized cancer treatment. These novel agents have provided promising treatment options in patients with different types of cancers. One of these agents is pembrolizumab, which works by blocking the binding of T-lymphocytes to programmed cell death ligand 1 receptors on tumor cells, thus enabling immune activation of T-lymphocytes against tumor cells. Pembrolizumab is commonly used in metastatic nonsmall cell lung cancer and melanoma. However, despite the remarkable efficacy this agent has achieved, multiple immune-related adverse events have been reported including hepatitis, colitis, thyroid dysfunction, and pneumonitis. Only 2 other cases of pericardial effusion as a side effect of pembrolizumab have been cited in the literature; however, its incidence may be on the rise. Despite the rarity of this side effect, its complications are potentially life threatening and no clear platform currently exists to help guide healthcare professionals in the management of these adverse events. Herein we present the case of a 66-year-old female who developed pericardial effusion as a side effect of pembrolizumab and review the data currently available to assist in the management of this life-threatening condition.