Isolated Adrenocorticotropic Hormone Deficiency Associated with Severe Hyperkalemia During Pembrolizumab Therapy in a Patient with Ureteral Cancer and an Ileal Conduit: A Case Report and Literature Review

Isolated Adrenocorticotropic Hormone Deficiency Associated with Sintilimab in the Treatment of Lung Adenocarcinoma: A Case Report and Literature Review

Isolated adrenocorticotropic hormone (ACTH) deficiency, a rare condition associated with immune checkpoint inhibitors, can manifest with symptoms such as fatigue, poor appetite, dizziness, hypotension, and hyponatremia. We present a case of a 52-year-old Chinese woman with stage IB lung adenocarcinoma who developed these symptoms after 8 months of treatment with sintilimab. Laboratory tests revealed hyponatremia, low ACTH and cortisol levels, and thyrotoxicosis. Imaging studies showed a Rathke's cleft cyst in the pituitary gland but normal adrenal glands. The patient was diagnosed with isolated ACTH deficiency and thyroid dysfunction and prescribed prednisone as replacement therapy, which improved her symptoms despite persistently low ACTH levels. This case highlights the importance of early diagnosis and treatment of immune checkpoint inhibitor-related endocrine disorders and provides insights into their management to enhance clinical practice and outcomes.

Slowly Progressive Secondary Adrenal Insufficiency Due to Pembrolizumab Administration in a Patient With a History of Pituitary Neuroendocrine Tumor

A 70-year-old man developed anorexia, general malaise, and hyponatremia with a serum sodium level of 120 mEq/L after the fifth cycle of pembrolizumab administration for bladder cancer. A rapid adrenocorticotropic hormone (ACTH) loading test result was within the normal range (basal and peak cortisol levels of 8.2 μg/dL and 20.0 μg/dL, respectively), and his serum sodium level recovered by salt loading. However, about two weeks later, his anorexia and malaise worsened, and his serum sodium level decreased to 122 mEq/L. A rapid ACTH loading test performed again four weeks after the first test showed a peak cortisol level of 13.4 μg/dL, and a corticotropin-releasing hormone (CRH) loading test showed basal ACTH and cortisol levels of 19 pg/mL and 6.3 μg/dL and peak levels of 34 pg/mL and 8.7 μg/dL, respectively. Therefore, secondary adrenal insufficiency (SAI) was diagnosed. Although he underwent nonfunctioning pituitary neuroendocrine tumor resection at the age of 55 years, the tumor was not significantly different from the postoperative findings. The possible cause of SAI was ACTH deficiency after pembrolizumab administration. Four months after diagnosis, the basal ACTH and cortisol levels had decreased from 19 to 17 pg/mL and from 6.0 to 3.2 μg/dL, respectively. We were able to follow the atypical, slowly progressive course of SAI due to pembrolizumab.

PD-1/PD-L1 inhibitors associated hypophysitis: An analysis from the FAERS database and case reports

To get a thorough understanding of PD-1/L1 inhibitor-related hypophysitis (PD-1/L1-irH), we utilized a combination of disproportionality analysis and case analysis to comprehensively characterize the clinical features of PD-1/L1-irH. Significant signals of hypophysitis were detected for all PD-1/PD-L1 inhibitors in the FAERS (FDA Adverse Event Reporting System). As revealed by both FAERS and the case analysis, PD-1/L1-irH occurred more commonly in males, PD-1 inhibitors users and patients older than 65 years. The median onset time was 101 days in FAERS and 8 cycles in the case analysis. In the case analysis, eight late-onset PD-1/L1-irHs occurred even after a discontinuation of several months (4-15 months). As revealed in FAERS, the outcome of PD-1/L1-irH tended to be poor, generally resulting in 64.66% hospitalization and 12.59% death. Fatigue was the most prominent symptom of PD-1/L1-irH, followed by anorexia, hyponatremia, and hypotension, as revealed by the analysis of 84 cases. Meanwhile isolated adrenocorticotropic (ACTH) deficiency was particularly prevalent for PD-1/L1-irH (85.71%), while gonadal hormones or posterior pituitary hormones deficiencies were rare. Glucocorticoids were administered to almost all cases (81/84), with a physiologic or stress dosage in 61.9% of cases, and a high-dose in 26.2% of cases. Most cases (58.3%) showed a favorable tumor response before diagnosis of PD-1/L1-irH. PD-1/L1-irH may occur throughout the whole therapy period even after discontinuation. Clinicians should pay more attention to PD-1 inhibitor users, males and older patients. Early diagnosis and prompt managements are crucial for PD-1/L1-irH as its potentially life-threatening nature.

Pembrolizumab-induced secondary adrenal insufficiency due to adrenocorticotrophic hormone deficiency in a patient with non-small-cell lung carcinoma: a case report

BACKGROUND

Pembrolizumab can cause immune-related adverse events such as adrenal insufficiency (AI). However, there is no consensus regarding appropriate monitoring of adrenal function during subsequent chemotherapy in patients who have received immune checkpoint inhibitors (ICIs) such as pembrolizumab.

CASE PRESENTATION

In this report, we discuss the case of a 60s-year-old male patient with non-small cell lung cancer receiving chemotherapy who developed secondary AI due to adrenocorticotrophic hormone (ACTH) deficiency 8 months after the discontinuation of pembrolizumab, which was 17 months after the initiation of pembrolizumab immunotherapy. After 5 months of chemotherapy, he developed fever and diarrhoea, after which chemotherapy was discontinued. Thereafter, he was hospitalised owing to the development of general fatigue and anorexia. Although cortisol and ACTH levels were not measured during chemotherapy, they were measured before hospitalisation, and secondary AI was suspected. After admission, a detailed endocrine workup was performed, and the patient was diagnosed with secondary AI due to ACTH deficiency. Treatment with hydrocortisone was initiated, which markedly improved his general fatigue and anorexia. The patient showed no evidence of progressive disease 9 months after the discontinuation of pembrolizumab.

CONCLUSIONS

Although rare, the possibility of AI should be considered in patients who have received ICIs when nonspecific symptoms develop during or after subsequent chemotherapy, and measurements of endocrine function (including cortisol and ACTH levels) should be performed.

Immune checkpoint inhibitor-induced isolated adrenocorticotropic hormone deficiency: a systematic review

Background

Immune checkpoint inhibitor-induced isolated adrenocorticotropic hormone deficiency (IAD) is a rare but potentially fatal disease.

Methods

We comprehensively searched the PubMed database and made a systematic review of immune checkpoint inhibitor-induced isolated adrenocorticotropic hormone deficiency. If the status of other anterior pituitary hormones was not mentioned, the case was excluded.

Results

We identified 123 cases diagnosed as immune checkpoint inhibitor-induced IAD, consisting of 44 female and 79 male patients. The average age of these patients was 64.3 ± 12.6 years old, and 67.5% were 60 years old or above. The majority (78.9%) of these patients received anti-programmed cell death protein-1 (anti-PD-1) antibodies or anti-programmed cell death ligand 1 (anti-PD-L1) antibodies or both, and 19.5% received combined therapy, sequential therapy, or both. A total of 26 patients received anti-cytotoxic T lymphocyte antigen 4 antibodies (anti-CTLA-4). The median ICI treatment cycle before the diagnosis of adrenal insufficiency was 8 (6, 12), and the median ICI treatment duration before the diagnosis of adrenal insufficiency was 6 (4, 8) months. Eleven cases developed IAD 1 to 11 months after discontinuation of ICIs. Fatigue and appetite loss were the most common symptoms, and surprisingly, there were two asymptomatic cases of IAD. Most patients (88 cases) had normal pituitary magnetic resonance imaging, only 14 cases reported mild atrophy or swelling pituitary gland, and 21 cases reported no imaging results. Most diagnoses were made by basal hormone levels, and pituitary stimulation tests were performed in only a part of the cases. No cases had been reported of discontinuation of ICI use due to IAD nor had there been any deaths due to IAD.

Conclusion

IAD was predominant in elderly male patients mainly receiving anti-PD-1 or anti-PD-L1 antibodies. It was sometimes difficult to recognize IAD at first glance since non-specific symptoms were common and asymptomatic cases of IAD were also reported. Although IAD can be deadly, it usually does not affect the continued use of ICIs.

Diagnostic strategies in adrenal insufficiency

PURPOSE OF REVIEW

Adrenal insufficiency (AI) is the clinical manifestation of deficient production of glucocorticoids with occasionally deficiency also in mineralocorticoids and adrenal androgens and constitutes a fatal disorder if left untreated. The aim of this review is to summarize the new trends in diagnostic methods used for determining the presence of AI.

RECENT FINDINGS

Novel aetiologies of AI have emerged; severe acute respiratory syndrome coronavirus 2 infection was linked to increased frequency of primary AI (PAI). A new class of drugs, the immune checkpoint inhibitors (ICIs) widely used for the treatment of several malignancies, has been implicated mostly with secondary AI, but also with PAI. Salivary cortisol is considered a noninvasive and patient-friendly tool and has shown promising results in diagnosing AI, although the normal cut-off values remain an issue of debate depending on the technique used. Liquid chromatography-mass spectrometry (LC-MS/MS) is the most reliable technique although not widely available.

SUMMARY

Our research has shown that little progress has been made regarding our knowledge on AI. Coronavirus disease 2019 and ICIs use constitute new evidence on the pathogenesis of AI. The short synacthen test (SST) remains the 'gold-standard' method for confirmation of AI diagnosis, although salivary cortisol is a promising tool.

Machine Learning Models Using Routinely Collected Clinical Data Offer Robust and Interpretable Predictions of 90-Day Unplanned Acute Care Use for Cancer Immunotherapy Patients

PURPOSE

Clinical management of patients receiving immune checkpoint inhibitors (ICIs) could be informed using accurate predictive tools to identify patients at risk of short-term acute care utilization (ACU). We used routinely collected data to develop and assess machine learning (ML) algorithms to predict unplanned ACU within 90 days of ICI treatment initiation.

METHODS

We used aggregated electronic health record data from 7,960 patients receiving ICI treatments to train and assess eight ML algorithms. We developed the models using pre-SARS-COV-19 COVID-19 data generated between January 2016 and February 2020. We validated our algorithms using data collected between March 2020 and June 2022 (peri-COVID-19 sample). We assessed performance using area under the receiver operating characteristic curves (AUROC), sensitivity, specificity, and calibration plots. We derived intuitive explanations of predictions using variable importance and Shapley additive explanation analyses. We assessed the marginal performance of ML models compared with that of univariate and multivariate logistic regression (LR) models.

RESULTS

Most algorithms significantly outperformed the univariate and multivariate LR models. The extreme gradient boosting trees (XGBT) algorithm demonstrated the best overall performance (AUROC, 0.70; sensitivity, 0.53; specificity, 0.74) on the peri-COVID-19 sample. The algorithm performance was stable across both pre- and peri-COVID-19 samples, as well as ICI regimen and cancer groups. Type of ICI agents, oxygen saturation, diastolic blood pressure, albumin level, platelet count, immature granulocytes, absolute monocyte, chloride level, red cell distribution width, and alcohol intake were the top 10 key predictors used by the XGBT algorithm.

CONCLUSION

Machine learning algorithms trained using routinely collected data outperformed traditional statistical models when predicting 90-day ACU. The XGBT algorithm has the potential to identify high-ACU risk patients and enable preventive interventions to avoid ACU.

Exploring a New Entity of Single-Agent Pembrolizumab-Associated Hypophysitis

Hypophysitis is the inflammation of the pituitary gland primary or secondary to local or systemic disease. It tends to occur more with cytotoxic T-lymphocyte-associated protein 4 inhibitors (10-15% of cases), which is a different entity compared to that associated with anti-program death 1 (anti-PD1) inhibitors. We describe a case of pembrolizumab-associated hypophysitis and conduct a systematic review of the literature. A 55-year-old woman with stage pT3aN1a (TNM stadium IIIb) melanoma presented with headache, nausea and fatigue three and a half months after starting pembrolizumab. Blood analyses revealed secondary adrenal failure, thyrotropic insufficiency and defective gonadotrophin secretion. An imaging study showed an enlarged pituitary gland with a homogeneous enhancement of the gland and pituitary stalk. Interruption of anti-PD1 therapy and administration of hormonal supplementation lead to clinical, biological and radiologic improvement after eight months. We identified 17 studies (20 patients) on single-agent pembrolizumab-associated hypophysitis. Patients were treated for melanoma (n=7; 33.3%), urogenital (n=5 ; 23.8%), lung (n=4 ; 19.0%), larynx (n=1 ; 4.8%), pharynx (n=1, 4.8%), breast (n=1, 4.8%) and colon (n=1, 4.8%) neoplasia. The time to onset of pituitary insufficiency was most frequently six months (range 1.5-39.0 months) after treatment initiation. The most prevalent hormonal defect was isolated adrenocorticotropic hormone (ACTH) deficiency. Four cases were reported with multiple central hormonal defects. In those patients, an enlarged pituitary gland was also observed. Our case has distinct features, including early disease onset after single-agent pembrolizumab initiation, panhypopituitarism and increased pituitary mass. These findings are in contrast with the majority of other cases of pembrolizumab-induced hypophysitis, as most patients present an isolated ACTH deficiency. Whether or not this is a new clinical entity warrants further investigation.

Risk assessment, diagnosis, and treatment of cancer treatment-related adrenal insufficiency

INTRODUCTION

Adrenal insufficiency (AI) is an easily treatable, potentially life-threatening condition, which is increasingly recognized in malignancy. The recent introduction of immune checkpoint inhibitors, in particular, and increasing use of tyrosine kinase inhibitors have increased the frequency of AI in patients with malignancy. A review is therefore warranted to summarize current knowledge on the topic and guide safe clinical practices.

AREAS COVERED

Malignancy may directly impact the hypothalamic-pituitary-adrenal axis and cause AI, or their treatment including surgery, radiotherapy and medication. In this narrative review, we discuss new causes of AI, recognition of suggestive clinical features, diagnosis and subsequent treatment, aiming to avoid potentially fatal adrenal crisis (AC). Standard literature searching and authors assessment of clinical applicability were used.

EXPERT OPINION

Adrenal insufficiency can be easily treated once identified but life threatening if unrecognized. While use of new agents such as immune checkpoint inhibitors (ICIs) is increasing, greater understanding of the mechanism of AI is needed to target prediction tools and enhance risk stratification.