Ipilimumab Lung Toxicity

Abstract

SESSION TITLE: Lung Pathology 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: A patient being treated with Ipilimumab developed granulomatous lung disease. CASE PRESENTATION: A 54 year old man was being treated for stage IIIc Melanoma with Ipilimumab. After his second infusion he developed a rash. Biopsy of a palmar lesion showed non-caseating granulomas. He developed dry cough and chest CT (Image 1) showed mediastinal lymphadenopathy and scattered sub centimeter lung nodules. The imaging findings were concerning for metastatic disease. A bronchoscopy with EBUS and fine needle aspiration of hilar and subcarinal lymph nodes was performed. Lymph node biopsy revealed non-caseating granulomas in both left hilar and subcarinal sites. Flow cytometry on lymph node FNA showed no clonal populations and a CD4/CD8 ratio of 4. The patient was treated with Prednisone for 2 months with resolution of his symptoms and improvement in CT findings (Image 2). He continues to receive Ipilimumab infusions for Melanoma therapy without any recurrence of his granulomatous disease. DISCUSSION: Novel immunotherapy agents have revolutionized the treatment of certain cancers in recent years. Some of these work by activating the immune system to aid in fighting tumor burden. Ipilimumab blocks CTLA-4, a T-cell activation checkpoint molecule, thereby promoting immunity against the tumor (1). It has been shown to improve survival in metastatic Melanoma and has become part of the standard treatment regimen (2). There have been case reports of a granulomatous sarcoid-like reaction to these medications (3). Lung manifestations can be mistaken for progression of the underlying malignancy. Clinicians should be aware of this important reaction and pursue tissue diagnosis to differentiate the two. CONCLUSIONS: Novel immunotherapy agents are being used to treat certain kinds of cancer. An important consideration of these treatments is the effect of activation of the immune system on other organs. A pulmonary sarcoid like reaction can resemble metastatic disease on imaging. Our case illustrates the importance of pursuing tissue diagnosis. A short course of steroids resulted in resolution of the pulmonary findings. Reference #1: O’Day SJ, et al. Targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4). Cancer, 110: 2614-2627. Reference #2: Hodi FS et al. Improved Survival with Ipilimumab in Patients with Metastatic Melanoma. N Engl J Med 2010; 363:711-23. Reference #3: Reule RB, North JP. Cutaneous and pulmonary sarcoidosis-like reaction associated with ipilimumab. J Am Acad Dermatol. 2013;69(5):e272-e273. DISCLOSURE: The following authors have nothing to disclose: Esha Oommen, Joanne Allam No Product/Research Disclosure Information