Focal immune-related pancreatitis occurring after treatment with programmed cell death 1 inhibitors: a distinct form of autoimmune pancreatitis?

Incidence of Pancreatic Injury and Pancreatitis in Patients Treated With Immune Checkpoint Inhibitors

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are being increasingly used to treat advanced malignancies. ICI-induced pancreatic injury (ICI-PI), which is an immune-related adverse event that may be a risk factor of ICI-associated pancreatitis, is not well documented in the literature.

METHODS

Consecutive patients who received ICIs for advanced malignancies from August 2015 through October 2022 were analyzed for the incidence of ICI-PI based on the Common Terminology Criteria for Adverse Events and ICI-associated pancreatitis. The imaging, clinical, and pathological findings of ICI-associated pancreatitis were also assessed.

RESULTS

This study enrolled 843 patients. In multivariable analyses, dual or simultaneous immunotherapy and ≥10 cycles of ICI administration were significant predictive factors for all grades of pancreatic injury, including grade ≥3. Notably, patients who received simultaneous immunotherapy exhibited a higher incidence of grade ≥3 pancreatic injuries compared with those receiving asynchronous immunotherapy in univariable analysis ( P = 0.032). One-fifth of the patients (16/70) with grade ≥3 pancreatic injuries had imaging evidence of pancreatitis similar to mild acute pancreatitis. ICI-associated pancreatitis was observed in 5.7% (48/843) of patients, including 1.8% (15/843) with moderate-to-severe pancreatitis (grade ≥2). Symptomatic cases (0.36%, 3/843) were treated with steroids with favorable outcomes. Immunohistochemistry for CD4 and CD8 revealed greater infiltration of CD8 + than CD4 + lymphocytes.

DISCUSSION

Simultaneous immunotherapy and dual immunotherapy are risk factors of ICI-PI. Although most patients diagnosed with ICI-PI and ICI-associated pancreatitis were asymptomatic and had a low mortality likelihood, long-term outcomes, including endocrine and exocrine function, should be carefully monitored.

Immune Checkpoint Inhibitor-induced Pancreatitis with Pancreatic Enlargement Mimicking Autoimmune Pancreatitis: A Case Report and Review of the Literature

A 61-year-old woman was administered 35 cycles of pembrolizumab for the treatment of recurrent endometrial cancer, achieving a complete response. She presented with asymptomatic pancreatic enlargement and elevated hepatobiliary enzymes, but amylase and lipase levels were within the normal ranges. Intrapancreatic bile duct stenosis due to pancreatic enlargement was present, mimicking autoimmune pancreatitis on computed tomography performed before the onset of clinical manifestations. A histological examination of a biopsy specimen showed lymphocyte and plasma cell infiltration with dense fibrosis in the stroma. The patient was successfully treated with oral prednisolone. There were no manifestations of recurrent pancreatitis after tapering the prednisolone dose.

The clinical characteristics of focal acute pancreatitis based on imaging diagnosis: comparison with non-localized acute pancreatitis- a preliminary result

BACKGROUND

Focal acute pancreatitis is a special type of acute pancreatitis, which diagnosis is based on image showing a focal mass formation in the pancreas. For acute pancreatitis with or without focal inflammatory enlargement, little is known on differences between them. Our purpose was to find differences between focal acute pancreatitis and non-localized acute pancreatitis.

METHODS

We reviewed the medical records of a total of 24 patients diagnosed with focal acute pancreatitis by imaging and clinical diagnosis, and 27 cases of acute pancreatitis which manifest non-localized pancreas inflammation were selected as the control group. The differences of the two groups were compared to describe their clinical characteristics.

RESULTS

Differences in bloating (4.2% VS 29.6%,P = 0.026), abdominal tenderness (58.3% VS 85.2%,P = 0.032), peripheral blood neutrophil ratio (60.1 ± 23.3VS 75.9 ± 12.6,P = 0.004), serum D-Dimer (0.40(0.25,0.98) VS 1.59(0.49,4.63),P = 0.008), serum GGT (40(25,91) VS120(22,383),P = 0.046), serum amylase(435(241,718) VS 591(394,1333),P = 0.044) and lipase(988(648,1067) VS 1686(525,2675),P = 0.027) between focal acute pancreatitis and non-localized acute pancreatitis groups were statistically significant. However, difference of the severity of two groups was not statistically significant (P = 1.000).

CONCLUSION

Compared with non-localized acute pancreatitis, changes in symptoms, signs and laboratory indicators of focal acute pancreatitis are non-obvious, however, there was no significant difference in the severity of two groups, indicating that we should pay more attention to diagnosis of focal acute pancreatitis in clinical practice.

Pancreatitis as immune-related adverse event during pembrolizumab therapy for multiple lung metastases from renal pelvic cancer

Introduction

Pembrolizumab administration has become the standard of care for patients with urothelial carcinoma, though a variety of adverse events have been reported. Presented here is a rare case of pancreatitis that occurred as an immune-related adverse event.

Case presentation

An 81-year-old man undergoing treatment with pembrolizumab for multiple lung metastases from renal pelvic cancer was presented with a fever and diagnosed with pancreatitis based on elevated pancreatic enzyme levels and imaging findings. There was no history of alcohol consumption or findings indicating gallstones, elevated liver enzymes, or abdominal complications. The patient was diagnosed with immune-related adverse event pancreatitis and treated with Lactate Ringer's solution (3000 mL/day) and steroids, during which his condition improved.

Conclusion

Although pancreatitis is a rare complication, it should always be considered as a potential immune-related adverse event in patients treated with an immune checkpoint inhibitor such as pembrolizumab.

Immune checkpoint inhibitors-related pancreatitis with fulminant type 1 diabetes mellitus: case report and literature review

Immune checkpoint inhibitors (ICIs) are increasingly being used in the treatment of advanced human malignancies. ICIs-related adverse events, including pancreatitis and diabetes, have been individually characterized in the literature. The co-occurrence of ICIs-related pancreatitis with diabetes is rare and easily overlooked, but it is often severe or fatal. We present a patient with renal tumor resection who was treated with injection of the PD-L1 inhibitor toripalimab and eventually developed acute pancreatitis and fulminant type 1 diabetes mellitus. In addition, we conducted a literature review of ICIs-related pancreatitis with diabetes. The case in our report presented with paroxysmal abdominal pain and loss of appetite. Intravenous fluids and insulin infusion improved the patient's pancreatitis and explosive hyperglycemia. This article suggests that ICIs can affect endocrine and exocrine functions of the pancreas, while providing information and new perspectives for the diagnosis and treatment of this challenging rare disease, helping inspire clinicians for the early identification and effective management of similar cases.

The diagnosis of immune-related pancreatitis disguised as multifocal lesions on MRI by endoscopic ultrasound-guided fine-needle biopsy: A case report

Immune checkpoint inhibitor (ICI)–related acute pancreatitis (irAP) is a rare, potentially life-threatening immune-related adverse event. Whereas CT and MRI remain first-line diagnostic imaging modalities, more patients are presenting with atypical irAP as ICI use increases. To appropriately manage these events, it is important to catalog these presentations and provide comprehensive clinical, radiological, and pathological descriptions to guide evidence-based practice. Here, we present the case of a 66-year-old man with advanced lung adenocarcinoma who, after the fifth course of toripalimab, developed epigastric discomfort and elevated serum amylase and lipase. irAP was suspected, but MRI revealed atypical, multifocal pancreatic lesions. To exclude metastases, an endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) was performed. EUS revealed a slightly swollen pancreas with heterogeneous echoic signals and scattered hyperechoic areas in the parenchyma without an obvious mass. Histopathological examination of the FNB revealed retention of the normal lobular pancreatic architecture with focal acinar atrophy associated with a CD8⁺ T lymphocyte-predominant infiltrate, further confirming the diagnosis of irAP. After starting glucocorticoids, his symptoms resolved, serum amylase and lipase rapidly decreased to normal, and the abnormal MRI features diminished. irAP can, therefore, present as multifocal lesions on MRI, and, when metastatic disease requires exclusion, EUS-FNB is an effective way to establish a definitive diagnosis. Refining the histopathological and immunopathological criteria for the diagnosis of irAP is now warranted.

Pembrolizumab-Induced Pancreatic Exocrine Insufficiency Complicated by Severe Hepatic Steatosis

Anti-programmed death receptor-1 (anti-PD-1) monoclonal antibodies (mAbs) are used to treat an increasing range of cancers. However, the distinct toxicity profile of immune-related adverse events (irAEs) is a frequent drawback of their clinical application. Among the more common irAEs are hepatitis and colitis, which are diagnosed and graded in patients based on elevated serum liver enzyme levels and increased stool frequency, respectively, and both of which often require treatment with high-dose corticosteroids. Herein, we describe the case of a patient who developed severe transaminase elevation and diarrhoea due to an unusual irAE, which was successfully treated without corticosteroids.

Clinical Characteristics of ICI-Related Pancreatitis and Cholangitis Including Radiographic and Endoscopic Findings

The indications for immune checkpoint inhibitors (ICIs) have expanded to include carcinomas of various organs. However, as ICI therapy expands, the management of immune-related adverse events (irAEs) has become a problem. ICI-related pancreatitis and cholangitis are relatively rare irAEs. Although some patients with ICI-related pancreatitis and cholangitis are asymptomatic and do not require treatment, there have been reports of patients who did not respond to immunosuppressive therapy and died. Thus, the pathogenesis of ICI-related pancreatitis and cholangitis should be clarified immediately. Currently, the role of endoscopy in the diagnosis and treatment of inflammatory pancreatic and biliary duct diseases is becoming increasingly important. In this review, we summarize clinical characteristics as well as radiographic and endoscopic findings of ICI-related pancreatitis and cholangitis.

Fatal Immune Checkpoint Inhibitor-related Pancreatitis

We herein report a case of fatal pancreatitis induced by an immune checkpoint inhibitor. A 62-year-old man with cancer of unknown primary was treated with pembrolizumab. After 12 cycles, immune-related pneumonitis developed and was treated with prednisolone. Three months later, pancreatitis developed, which was successfully treated with hydration and protease inhibitors. Eight months later, another attack of pancreatitis occurred, which did not respond to therapy, including high-dose corticosteroids, and he eventually died. This is the first report describing fatal immune checkpoint inhibitor-related pancreatitis. Despite the rarity of this complication, attention should be paid to its potential severity and treatment.

The safety and efficacy of pembrolizumab for the treatment of non-small cell lung cancer

Introduction: Lung cancer is the leading cancer-related cause of death worldwide. The introduction of immune checkpoint inhibitors (ICIs) for the treatment of lung cancer has significantly improved the outcome of these patients. Pembrolizumab, a monoclonal IgG4-kappa antibody against programmed-death-1 (PD-1) protein, nowadays represents a standard of care for NSCLC patients. Although it has a favorable toxicity profile, some immune-related adverse events (irAEs) can be life-threatening, therefore its knowledge may help to optimize the care of these patients.Areas covered: The authors review data regarding the efficacy and safety of pembrolizumab from the most relevant clinical trials as well as toxicities reported in the clinical use. Special considerations of use in special populations will be noted. Finally, its toxicity profile will be compared with other ICIs used in NSCLC.Expert opinion: In the scenario of NSCLC, pembrolizumab shows a favorable safety profile with less than 10% serious immune-related adverse events (irAEs) when used in monotherapy and without adding relevant extra-toxicity to chemotherapy when used in combination. Monotherapy with pembrolizumab is associated with better health-related quality of life than chemotherapy. Early recognition and appropriate treatment of irAEs is of prime importance as most are reversible if correctly managed. Rechallenge with pembrolizumab is frequently feasible.