Outcomes of patients with cancer and sarcoid-like granulomatosis associated with immune checkpoint inhibitors: A case-control study

Resolution of multiorgan sarcoid-like reaction after treatment of renal cell carcinoma

Sarcoid -like reactions (SLRs) can occur in several malignancies adjacent to primary tumour location or the draining lymph nodes. The presence of peritumoural and intratumoural SLR in patients suffering from renal cell carcinoma (RCC) has been reported in few instances. However, the association of RCC with SLR in spleen, liver and other organs in the absence of systemic sarcoidosis is very rare.We present an unusual case of a gentleman in his 30s, who presented with a lesion in the left kidney along with non-specific lesions (likely granulomatous) in liver, spleen and lungs. Partial Nnephrectomy specimen confirmed conventional/clear cell RCC. The histopathology revealed an extensive epithelioid granulomatous reaction affecting both peritumoural and intratumoural areas. Follow-up images demonstrated an almost complete resolution of lesions in the spleen, liver and lungs. Our case supports the hypothesis that non-caseating granulomas of SLR could be a manifestation of an immunologically mediated antitumour response.

Sarcoidosis-like reactions in metastatic renal cell carcinoma patients treated with immune-based combinations

Aim: The incidence of drug-induced sarcoidosis-like reactions (DISR) in patients treated with immune checkpoint inhibitors (ICIs) is rising. We determine the incidence and characteristics of DISR in a metastatic renal cell carcinoma (mRCC) population. Methods: We retrospectively reviewed clinico-radiological data of 83 mRCC patients treated at a single institution with immune-based combinations. Results: 15 patients received immune-doublet (ipilimumab-nivolumab), while 68 patients received other immune-based combinations. Two cases of DISR (2.4%) were evidenced, with enlargement of mediastinal lymph nodes that mimicked disease progression, thus requiring a biopsy which showed histological features of DISR. Conclusion: In our series of the incidence of DISR, radiological and clinical features, are in line with literature. DISR diagnosis is often only radiological, and its occurrence is possibly associated with a better outcome.

The Utility of Laboratory Investigations for the Assessment and Management of Rheumatic Immune Related Adverse Events

Immune checkpoint inhibitors (ICIs) have greatly improved survival of several cancers with historically very poor prognosis. ICIs act by stimulating the patient's own immune system to fight cancer. Simultaneously, this immune activation can lead to immune-related adverse events (irAEs), including rheumatic manifestations (Rh-irAEs). Rh-irAEs mimic primary rheumatic diseases including arthritis, polymyalgia rheumatica, myositis, vasculitis, sarcoidosis, and sicca. This article summarizes the latest evidence regarding the utility of laboratory investigations in Rh-irAEs.

The 5th edition of the World Health Organization Classification of mature lymphoid and stromal tumors - an overview and update

The purpose of this review is to give an overview on the conceptual framework and major developments of the upcoming 5th edition of the World Health Organization (WHO) Classification of Haematolymphoid tumours (WHO-HAEM5) and to highlight the most significant changes made in WHO-HAEM5 compared with the revised 4th edition (WHO-HAEM4R) of lymphoid and stromal neoplasms. The changes from the revised 4th edition include the reorganization of entities by means of a hierarchical system that is realized throughout the 5th edition of the WHO classification of tumors of all organ systems, a modification of nomenclature for some entities, the refinement of diagnostic criteria or subtypes, deletion of certain entities, and introduction of new entities. For the first time, tumor-like lesions, mesenchymal lesions specific to lymph node and spleen, and germline predisposition syndromes associated with the lymphoid neoplasms are included in the classification.

Sarcoid-like Reactions to Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICIs) can cause immune-mediated cutaneous adverse events, including sarcoid-like reactions. The aim of this study was to retrospectively analyze clinical and histologic data from patients who developed cutaneous sarcoid-like reactions between 2019 and 2022 while under treatment with ICIs. We studied 7 patients (6 women and 1 man) with a median age of 65years. Median time to onset of symptoms was 4months. The most common presentation was papular sarcoidosis of the knees followed by subcutaneous sarcoidosis. Diagnosis was confirmed histologically in all cases, and no differences were observed relative to idiopathic sarcoidosis. Discontinuation of ICI therapy was required in just two patients. ICI-induced sarcoid-like reactions tend to be mild and generally do not require treatment discontinuation. Histologic confirmation is essential for distinguishing these reactions from tumor progression.

[Translated article] Sarcoid-like Reactions to Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICIs) can cause immune-mediated cutaneous adverse events, including sarcoid-like reactions. The aim of this study was to retrospectively analyze clinical and histologic data from patients who developed cutaneous sarcoid-like reactions between 2019 and 2022 while under treatment with ICIs. We studied 7 patients (6 women and 1 man) with a median age of 65years. Median time to onset of symptoms was 4months. The most common presentation was papular sarcoidosis of the knees followed by subcutaneous sarcoidosis. Diagnosis was confirmed histologically in all cases, and no differences were observed relative to idiopathic sarcoidosis. Discontinuation of ICI therapy was required in just two patients. ICI-induced sarcoid-like reactions tend to be mild and generally do not require treatment discontinuation. Histologic confirmation is essential for distinguishing these reactions from tumor progression.

Sarcoidosis-like reaction induced by immune checkpoint inhibitor in a patient with hepatocellular carcinoma: a case report

Nowadays, immune checkpoint inhibitors (ICI) have become the cornerstone of treatment for many tumors, either as monotherapy or in combination with other therapies. However, these drugs are associated with several new side effects that need early detection. We present the case of a 41-year-old male patient who has been diagnosed with advanced hepatocellular carcinoma (HCC) with metastatic retroperitoneal lymph nodes and a subdiaphragmatic metastatic lesion, undergoing second-line treatment with a combination of nivolumab and ipilimumab. After completing four cycles, the patient was admitted to the hospital due to intermittent fever and profuse sweating. A CT scan showed multiple pathologically enlarged lymph nodes in several locations, raising suspicion of disease progression. The patient's clinical progress was favorable after symptomatic treatment (antipyretics) and was discharged one week after admission. Several days later, the patient complained about painful bilateral ocular redness and was diagnosed with bilateral anterior uveitis. Further blood tests showed elevated angiotensin-converting enzyme (ACE) levels of 67 U/L (normal range: 8 - 52) and decreasing alpha-fetoprotein (AFP) levels of 698 ng/mL (previously 1210 ng/mL), indicative of non-progression of the oncological disease. Finally, an excisional biopsy confirmed the presence of non-necrotizing granulomatous lymphadenitis, leading to the diagnosis of sarcoidosis-like reaction (SLR) induced by immunotherapy as the etiology of the polyadenopathy syndrome. SLR, although uncommon, is an adverse effect of ICI treatment resulting from immune system dysregulation, which can mimic disease progression. It is crucial to be aware of this adverse event and to understand the optimal management approach.

Differential diagnosis of pulmonary sarcoidosis: a review

Diagnosing pulmonary sarcoidosis raises challenges due to both the absence of a specific diagnostic criterion and the varied presentations capable of mimicking many other conditions. The aim of this review is to help non-sarcoidosis experts establish optimal differential-diagnosis strategies tailored to each situation. Alternative granulomatous diseases that must be ruled out include infections (notably tuberculosis, nontuberculous mycobacterial infections, and histoplasmosis), chronic beryllium disease, hypersensitivity pneumonitis, granulomatous talcosis, drug-induced granulomatosis (notably due to TNF-a antagonists, immune checkpoint inhibitors, targeted therapies, and interferons), immune deficiencies, genetic disorders (Blau syndrome), Crohn's disease, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and malignancy-associated granulomatosis. Ruling out lymphoproliferative disorders may also be very challenging before obtaining typical biopsy specimen. The first step is an assessment of epidemiological factors, notably the incidence of sarcoidosis and of alternative diagnoses; exposure to risk factors (e.g., infectious, occupational, and environmental agents); and exposure to drugs taken for therapeutic or recreational purposes. The clinical history, physical examination and, above all, chest computed tomography indicate which differential diagnoses are most likely, thereby guiding the choice of subsequent investigations (e.g., microbiological investigations, lymphocyte proliferation tests with metals, autoantibody assays, and genetic tests). The goal is to rule out all diagnoses other than sarcoidosis that are consistent with the clinical situation. Chest computed tomography findings, from common to rare and from typical to atypical, are described for sarcoidosis and the alternatives. The pathology of granulomas and associated lesions is discussed and diagnostically helpful stains specified. In some patients, the definite diagnosis may require the continuous gathering of information during follow-up. Diseases that often closely mimic sarcoidosis include chronic beryllium disease and drug-induced granulomatosis. Tuberculosis rarely resembles sarcoidosis but is a leading differential diagnosis in regions of high tuberculosis endemicity.

Granulomatous and Sarcoid-like Immune-Related Adverse Events following CTLA4 and PD1 Blockade Adjuvant Therapy of Melanoma: A Combined Analysis of ECOG-ACRIN E1609 and SWOG S1404 Phase III Trials and a Literature Review

BACKGROUND

Treatment with immune checkpoint inhibitors (ICIs) has been linked to granulomatous and sarcoid-like lesions (GSLs) affecting different organs. This study sought to evaluate GSL incidence in patients with high-risk melanoma treated with cytotoxic T-lymphocyte antigen 4 (CTLA4) or programmed cell death 1 (PD1) blockade adjuvant therapy in two clinical trials: ECOG-ACRIN E1609 and SWOG S1404. Descriptions and GSL severity ratings were recorded.

METHODS

Data were collected from ECOG-ACRIN E1609 and SWOG S1404. Descriptive statistics along with GSL severity grades were reported. Additionally, a literature review for such cases was summarized.

RESULTS

A total of 11 GSL cases were reported among 2878 patients treated with either ICI or with High-Dose Interferon Alfa-2b (HDI) in ECOG-ACRIN E1609 and SWOG S1404 trials. Cases were numerically more commonly reported with ipi10, followed by pembrolizumab, ipi3, and HDI, respectively. Most of the cases were grade III. Further, organs involved included lung, mediastinal lymph nodes, skin and subcutaneous tissue, and eye. Furthermore, a summary of 62 reports in the literature was described.

CONCLUSIONS

GSLs following anti-CTLA4 and anti-PD1 antibody therapy in patients with melanoma were reported unusually. Reported cases ranged in grade from I to III and appeared manageable. Careful attention to these events and their reporting will be essential to better guide practice and management guidelines.

Retrospective study of the incidence of sarcoidosis-like reaction in patients treated with immunotherapy

AIM

To assess the frequency of radiographically evident drug-induced sarcoidosis-like reaction (DISR) in patients treated with anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) therapy, anti-programmed cell death protein 1 (PD-1) therapy, or a combination of both in a single centre.

MATERIALS AND METHODS

The images and medical records of 457 patients with metastatic melanoma or head and neck cancer treated with either anti-CTLA-4 therapy, anti-PD-1 therapy, or a combination of both at University of California medical centre were reviewed retrospectively and the incidence of radiological manifestations of DISR was assessed among these treatment groups.

RESULTS

Radiological manifestations of DISR were found in 19/457 patients (4.1%). The mean interval from the initiation of immunotherapy to development of DISR was 5.5 months (range 2.3-13.5 months). Mean interval from radiological detection of DISR to imaging evidence of resolution was 5.8 months (range 1.6-18.3 months). Three patients out of 81 (3.7%), 11/297 (3.7%), and 5/79 (6.3%) developed sarcoidosis-like reaction after treatment with anti-CTLA-4 antibody, anti-PD-1 antibody, and a combination of both, respectively. Most patients with DISR were asymptomatic and did not require systemic therapy. Most patients did not demonstrate concomitant increased maximum standardised uptake value (SUVmax) in other organs on their integrated 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT).

CONCLUSIONS

In the present retrospective study of patients treated with immune checkpoint inhibitors (ICIs), DISR occurred in approximately 3.7% of patients treated with either anti-CTLA-4 or anti-PD-1 antibody and 6.3% of patients treated with a combination of both.

Sarcoid-Like Granulomatosis of the Lung Related to Durvalumab After Chemoradiation for Pulmonary Squamous Cell Carcinoma

Sarcoid-like granulomatosis is a unique immune-related adverse event (irAE) in cancer patients treated with immune checkpoint inhibitors (ICIs). This irAE is infrequent, reported to range from 2% to 22.2% of melanoma treated with ICI. In a case of granulomatosis localized in the lung, it is difficult to differentiate granulomatosis from cancer progression or metastases. Herein, we report a case of ICI-induced sarcoid-like granulomatosis of the lung, which was confusable with localized recurrence of the primary lung cancer. A 56-year-old woman with c-stage IIIA of pulmonary squamous cell carcinoma in the right lower lobe received chemo-radiotherapy with two courses of cisplatin and vinorelbine and concurrent thoracic irradiation, followed by 1-year durvalumab consolidation therapy. The tumor in the right S₆ grew and presented abnormal uptake by fluorodeoxyglucose positron emission tomography (FDG-PET), 1.5 years after durvalumab. Neither computed tomography (CT) nor FDG-PET found mediastinal and distant metastases. She underwent right lower lobe lobectomy. Histopathologically, the tumor and sampled lymph nodes contained no residue of carcinoma cells but presented diffuse epithelioid granuloma with infiltration of inflammatory cells, partial necrotic lesions and many multinucleated giant cells. In immunohistochemical stains, CD3⁺ and CD8⁺ T cells predominantly infiltrated, while there were few CD4⁺ T cells and a small number of CD20⁺ B cells. We followed her without steroid and other immunosuppressant drug. We should pay attention to the development of sarcoid-like granulomatosis as a rare irAE, which is difficult to be differentiated from cancer progression.

Endobronchial ultrasound-guided transbronchial needle aspiration in patients with previously treated malignancies: diagnostic performance and predictive value

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration is a minimally invasive and effective sampling approach for patients with mediastinal or hilar lymphadenopathy. Increased recognition of the ultrasonographic features revealed the value of its images in predicting mediastinal lymph node malignancy. However, its diagnostic validity and the predictive value of its ultrasonographic features have not been demonstrated well in patients after systemic anti-tumor therapy. This study aimed to evaluate the efficiency of endobronchial ultrasound-guided transbronchial needle aspiration in patients with suspicious lymph nodes after anti-tumor therapy.

METHODS

We retrospectively reviewed cases of endobronchial ultrasound-guided transbronchial needle aspiration performed between January 2019 and August 2021 at a single tertiary hospital center. Patients with suspected mediastinal or hilar lymph nodes within 5 years of systemic anti-tumor therapy were enrolled. Final diagnoses were determined by pathologic diagnoses of samples from transbronchial needle aspiration, surgery, or follow-up for at least 6 months. Ultrasonographic features were analyzed to assess the predictive value of malignant lymph nodes after treatment.

RESULTS

Overall, 168 lymph nodes of 138 patients were analyzed. Among 110 (65.5%) malignant lymph nodes, 75 originated from lung cancers; the other 35 were from other malignancies. No complications related to endobronchial ultrasound-guided transbronchial needle aspiration were observed. Of 58 negative results of transbronchial needle aspiration, 51 were proven to be true negatives; 7 were false. The overall sensitivity and the negative predictive value were 94.02% and 87.93%, respectively. Univariate and multivariate analysis revealed the absence of central hilar structure and short axis > 10 mm as independent predictive factors for malignancy.

CONCLUSIONS

Endobronchial ultrasound-guided transbronchial needle aspiration performs satisfactorily in diagnosing mediastinal and hilar lymphadenopathy even after anti-tumor treatment.

The Meaning of Lymphadenopathies During Adjuvant Durvalumab After Chemoradiotherapy for Lung Cancer: Thinking Beyond Disease Progression

Immune-checkpoint inhibitors (ICIs) have become the mainstay of treatment for many malignancies. With this new strategy, relevant immune-related adverse events (irAEs) have been reported, some of which can be mistaken for disease progression. To better illustrate the current challenges in diagnosing and managing a patient under adjuvant ICI treatment, we present the case of a 67-year-old female patient with stage IIIB unresectable, epidermal growth factor receptor (EGFR)-mutated, non-small-cell lung cancer who was initially treated with chemoradiotherapy, followed by immunotherapy with durvalumab. During the course of immunotherapy, the patient presented with madarosis and erythematous and endured skin lesions, in addition to lymphadenopathies and pulmonary infiltrates. She was started on first-line palliative treatment with an EGFR tyrosine kinase inhibitor. After reviewing the case, a multidisciplinary team meeting suggested diagnostic procedures, including a transbronchial needle aspiration from mediastinal lymph nodes. The histologic examination showed chronic systemic inflammation and non-caseating granulomas of the sarcoid type. In this case, palliative treatment was suspended and systemic therapy with prednisolone was initiated. The patient became asymptomatic and the previously observed radiologic abnormalities resolved. This case highlights the importance of early recognition and appropriate treatment of irAEs, mainly because these conditions remain poorly understood and are probably underdiagnosed. Considering differential diagnosis is paramount to guide clinical management, despite curative or palliative treatment intent.

Case Report: Sarcoid-Like Reactions and Tertiary Lymphoid Structures Following Dual Checkpoint Inhibition in a Patient with Early-Stage Lung Adenocarcinoma

Immune checkpoint inhibitor-induced sarcoid-like reactions and tertiary lymphoid structures (TLSs) are increasingly recognized but rarely reported in the same patient. We report a patient with lung adenocarcinoma who displayed sarcoid-like reactions in intrathoracic lymph nodes and tertiary lymphoid structures in surgical tumor after neoadjuvant therapy with nivolumab plus ipilimumab. Pathological examination revealed 50% residual tumor cells after treatment, and the CT evaluation of the primary tumor showed a stable disease. The patient experienced a recurrence eight months after surgery. To identify immune correlates of the limited response to immunotherapy, we conducted genomic and transcriptional assays, multiplex immunoassay, and multiplex immunohistochemistry on the pre- and post-immunotherapy tumor, lymph node, and plasma samples. TP53 R181C, KRAS G12C and SMAD4 R361H were identified as driver mutations of the tumor. In addition to abundant infiltrated lymphocytes, immunotherapy induced high levels of inhibitory components in post-treatment tissue samples, especially the FOXP3⁺ regulatory T cells in tumor and PD-L1 expression in the lymph node. Despite abundant TLSs in the post-treatment tumor, most TLSs were immature. Moreover, increasing levels of circulating checkpoint proteins BTLA, TIM-3, LAG-3, PD-1, PD-L1, and CTLA4 were observed during immunotherapy. Collectively, our observations revealed that high levels of immunosuppressive molecules in tumor, lymph nodes and/or in peripheral blood might indicate poor outcomes after immunotherapy, even in the setting of a patient with concurrent sarcoid-like reactions and tertiary lymphoid structures.

Clinical Features, Histopathology and Differential Diagnosis of Sarcoidosis

Sarcoidosis is a chameleon disease of unknown etiology, characterized by the growth of non-necrotizing and non-caseating granulomas and manifesting with clinical pictures that vary on the basis of the organs that are mainly affected. Lungs and intrathoracic lymph nodes are the sites that are most often involved, but virtually no organ is spared from this disease. Histopathology is distinctive but not pathognomonic, since the findings can be found also in other granulomatous disorders. The knowledge of these findings is important because it could be helpful to differentiate sarcoidosis from the other granulomatous-related diseases. This review aims at illustrating the main clinical and histopathological findings that could help clinicians in their routine clinical practice.