Abstract
BackgroundImmune checkpoint inhibitor therapy has changed the standard drug therapy for relapsed or advanced non-small cell lung cancer; its efficacy is well-recognized by pulmonary physicians, oncologists, and thoracic surgeons. Nivolumab, one of the anti-programmed cell death 1 antibodies, was the first immune checkpoint inhibitor to be approved and is used as a standard second-line regimen for patients with non-small cell lung cancer irrespective of the expression of programmed cell death ligand 1. Programmed cell death 1 antibodies have been generally confirmed to be less toxic than conventional cytotoxic chemotherapy, although unusual immune-related adverse events such as type I diabetes mellitus, adrenal failure, and myasthenia gravis may occur with a very low incidence. A case of severe grade V immune-related thrombocytopenia after two courses of nivolumab as second-line therapy for relapsed non-small cell lung cancer is reported.Case presentationAn 82-year-old Japanese woman with relapsed lung adenocarcinoma was treated with nivolumab as second-line systemic therapy at our institute. Her laboratory data indicated thrombocytopenia suspected to be an immune-related adverse event following two courses of nivolumab. Subsequently, she developed a massive pulmonary hemorrhage and left cerebral infarction despite intensive treatment including systemic steroid therapy. Although there have been a few reports of thrombocytopenia caused by nivolumab, this is the first report of grade V thrombocytopenia following administration of nivolumab for relapsed non-small cell lung cancer.ConclusionA very difficult case of grade V immune-related thrombocytopenia after the administration of nivolumab as second-line therapy for relapsed lung adenocarcinoma was described. Immune-related thrombocytopenia is a rare adverse event, but it must be considered a possible complication because it may become critical once it has occurred.
Highlights
Immune checkpoint inhibitor therapy has changed the standard drug therapy for relapsed or advanced non-small cell lung cancer; its efficacy is well-recognized by pulmonary physicians, oncologists, and thoracic surgeons
Immune checkpoint inhibitors (ICIs), such as the anti-programmed cell death 1 (PD-1) antibodies nivolumab [1, 2] and pembrolizumab [3] or the anti-programmed cell death ligand 1 (PD-L1) antibodies atezolizumab [4] and durvalumab [5], are recognized as standard second-line therapies for advanced or relapsed non-small cell lung cancer (NSCLC), and use of ICIs is expanding to many other malignancies
ICIs are generally recognized to be less toxic than cytotoxic chemotherapy, but they may cause unusual immunerelated adverse events, such as thyroiditis, type I diabetes mellitus, adrenal failure, or myasthenia gravis, while thrombocytopenia has been reported in only a few cases of advanced NSCLC [6,7,8,9]
Summary
Immune checkpoint inhibitor therapy has changed the standard drug therapy for relapsed or advanced non-small cell lung cancer; its efficacy is well-recognized by pulmonary physicians, oncologists, and thoracic surgeons. Programmed cell death 1 antibodies have been generally confirmed to be less toxic than conventional cytotoxic chemotherapy, unusual immune-related adverse events such as type I diabetes mellitus, adrenal failure, and myasthenia gravis may occur with a very low incidence. Case presentation: An 82-year-old Japanese woman with relapsed lung adenocarcinoma was treated with nivolumab as second-line systemic therapy at our institute Her laboratory data indicated thrombocytopenia suspected to be an immune-related adverse event following two courses of nivolumab. ICIs are generally recognized to be less toxic than cytotoxic chemotherapy, but they may cause unusual immunerelated adverse events (ir-AEs), such as thyroiditis, type I diabetes mellitus, adrenal failure, or myasthenia gravis, while thrombocytopenia has been reported in only a few cases of advanced NSCLC [6,7,8,9]. The first case of grade V thrombocytopenia caused by nivolumab in a patient with relapsed NSCLC is presented, and the purpose of this report is to act as a warning that ICI-induced fatal thrombocytopenia could occur, it is very rare
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