LOCULATED PERICARDIAL EFFUSION SECONDARY TO PEMBROLIZUMAB

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pembrolizumab is a humanized antibody that targets the programmed cell death 1 (PD-1) receptor of lymphocytes. Pembrolizumab is a first-line, single-agent treatment of metastatic non-small cell lung cancer in patients with tumors with high PD-L1 expression (tumor proportion score ≥ 50%) [1]. Pericardial effusion is very rarely reported side effect of pembrolizumab and only reported three times in the literature. We report a loculated pericardial effusion with early tamponade physiology in a patient actively treated with pembrolizumab CASE PRESENTATION: 62 year-old man with a history of poorly-differentiated, metastatic squamous cell carcinoma of the right upper lobe (PD-1 positive), diagnosed 6 months prior to admission, presented with abnormal chest imaging (Figures 1,2,3). He was found to have a large pericardial effusion on CT Thorax. The patient had been initiated on pembrolizumab 4 months prior. The patient underwent a transthoracic echocardiogram that demonstrated a large pericardial effusion suggestive of tamponade physiology (figure 4). A pericardial window with subxiphoid approach was performed with pericardial biopsy. A total of 400ml of orange fluid was drained. The pericardial biopsy and fluid cytology showed benign chronic inflammation with microbiological workup. The patient was discharged home seven days later. Pembrolizumab was ultimately discontinued after exclusion of infectious, inflammatory or malignant etiology. Corticosteroids therapy was initiated. DISCUSSION: Immune checkpoint inhibitors have been increasingly used for treatment various malignant therapies. Reported side-effects include cases of hepatitis, colitis, pneumonitis and thyroiditis. Acute immune-related pericarditis has been reported with two other PD-1 inhibitors, nivolumab and ipilimumab. However, this case represents the fourth case of pembrolizumab associated pericardial effusion. Most cases have been reported to happen in the first 3 months of starting immunotherapy [2]. Pericardial biopsy is of paramount importance as it will decide whether the pericardial effusion is of malignant origin or an autoimmune reaction to pembrolizumab. Immune-related pericarditis is reported to respond to steroids and such cases need to monitor for recurrence of pericardial effusions CONCLUSIONS: Immune related pericarditis is an important side effect of PDL-1 inhibitors. It maybe a sign of response to immunotherapy in the correct clinical setting. Diagnosing and managing cardiac tamponade is very important in these patients. Reference #1: Garon EB, Rizvi NA, Hui R, et al; KEYNOTE-001 Investigators. Pembrolizumab for the treatment of non-small-cell lung cancer. N Engl J Med. 2015;372(21):2018-2028. [PubMed 25891174] Reference #2: Non-parallel anti-tumour effects of pembrolizumab: a case of cardial tamponade - Tachihara - 2019 - Respirology Case Reports - Wiley Online Library Kolla BC, and Patel MR. 2016. DISCLOSURES: No relevant relationships by Adam Austin, source=Web Response No relevant relationships by Wafic Itani, source=Web Response No relevant relationships by Lezah McCarthy, source=Web Response No relevant relationships by Kristoffer Neu, source=Web Response