RS3PE syndrome induced by Pembrolizumab

Development of Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome with Pembrolizumab for Lung Squamous Cell Carcinoma

Immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs). There are a few case reports of remitting seronegative symmetrical synovitis with pitting edema syndrome (RS3PE) as an irAE. We herein report a 49-year-old Japanese man who developed acute-onset polyarthralgia and edema of the back of both hands and bilateral lower legs after pembrolizumab administration for lung cancer. The patient's lung cancer was in complete remission, leading to the diagnosis of RS3PE induced by pembrolizumab rather than malignancy. When patients show RS3PE during ICI treatment, rheumatologists should consider the possibility of an irAE after excluding malignancy and systemic diseases.

Immune Checkpoint Inhibitor-Associated Remitting Seronegative Symmetrical Synovitis With Pitting Edema: Description of a New Entity by CanRIO

OBJECTIVE

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is characterized by symmetrical synovitis with pitting edema and negative rheumatoid factor (RF). It has been described in a setting of malignancy, suggesting a paraneoplastic association. With the increasing use of immune checkpoint inhibitors (ICIs) for the treatment of cancers and emergence of immune-related adverse events (irAEs), our objective was to identify and describe cases of ICI-associated RS3PE (ICI-RS3PE) and compare them to non-ICI-RS3PE.

METHODS

The Canadian Research Group of Rheumatology in Immuno-Oncology (CanRIO) network is a collaboration of Canadian rheumatologists with experience in the management of patients with rheumatic irAEs (Rh-irAEs). Standardized data on adult patients with Rh-irAE have been collected as part of retrospective and prospective cohorts. In this study, detailed information on all cases of ICI-RS3PE from both cohorts were extracted and analyzed.

RESULTS

We identified 11 cases of ICI-RS3PE. The most frequently observed malignancy was nonsmall cell lung cancer (4 of 11), followed by malignant melanoma (2 of 11) and cutaneous squamous cell carcinoma (2 of 11). The median time to onset of ICI-RS3PE was 26 weeks from ICI start and 52 weeks from diagnosis of malignancy. Seven patients had stable cancer prior to onset of ICI-RS3PE, 3 had partial response, and 1 had complete response. All patients received glucocorticoids. Conventional synthetic disease-modifying antirheumatic drugs (csDMARD) were needed in 10 patients.

CONCLUSION

ICI-RS3PE may be an independent Rh-irAE, separate from paraneoplastic RS3PE. The symptoms of ICI-RS3PE responded well to glucocorticoids, but concomitant treatment with csDMARDs may be necessary.

Remitting seronegative symmetrical synovitis with pitting edema syndrome induced by pembrolizumab in patient with urothelial carcinoma

Introduction

Recent introduction of immuno-oncology drugs such as pembrolizumab has resulted in improved outcomes for urothelial carcinoma patients. However, immune-related adverse events generally show great variance and are often difficult to diagnose and control.

Case presentation

An 84-year-old Japanese male with urothelial carcinoma metastasis to the lungs after a laparoscopic left radical nephroureterectomy procedure was treated with pembrolizumab, an immuno-oncology drug, as second-line therapy. At week 6, inflammatory arthralgia involving the hands and shoulder joints, and edema of the hands were presented. The diagnosis was remitting seronegative symmetrical synovitis with pitting edema syndrome. Pembrolizumab was discontinued, and oral corticosteroid therapy was started. Two months later, pembrolizumab treatment was resumed because of a significant improvement in patient condition.

Conclusion

Although rare, immune-related adverse events are occasionally encountered during the use of immune-oncology drugs; thus, early diagnosis and appropriate treatment are important.