An autopsy case of severe acute pancreatitis induced by administration of pazopanib following nivolumab

Clinical characteristics of immune checkpoint inhibitor-related pancreatic injury with pancreatitis in patients with advanced malignancies

BACKGROUND/PURPOSE

Immune checkpoint inhibitor (ICIs) therapy can cause immune checkpoint inhibitor-related pancreatic injury (ICI-PI). This study aimed to elucidate the clinical characteristics of ICI-PI and explore treatment approaches.

METHODS

We retrospectively analyzed data from patients with malignancies treated with ICIs at Nagoya University Hospital between September 2014 and June 2023. ICI-PI and pancreatitis were identified and classified using the Common terminology Criteria for Adverse Events (CTCAE) ver.5.0, and the patients with ICI-PI with/without pancreatitis were analyzed.

RESULTS

This study included data from 930 patients treated with ICIs. Of these, eight (0.85 %) and 10 (1.08 %) patients were diagnosed with ICI-PI without and with pancreatitis, respectively. Five of the 10 patients received standard pancreatitis treatment, while three received additional glucocorticoid therapy. One patient experienced recurrent pancreatitis and developed a pancreatic pseudocyst, which improved after high-dose glucocorticoid treatment. ICI rechallenge was pursued in five patients. Two patients received ICIs without an interval.

CONCLUSIONS

ICI-PI with pancreatitis is rare but has become more prevalent with the increasing use of ICIs. Future prospective multicenter studies are needed to confirm these findings and develop standardized diagnostic and treatment protocols.

Immune checkpoint inhibitors-induced pancreatitis: a systematic review and real-world pharmacovigilance analysis

Purpose

Immune checkpoint inhibitors-induced pancreatitis (ICIs-P) is an uncommon immune-related adverse event. The available evidence consists mostly of case reports, case series, and narrative reviews. This research focuses on the clinical characteristics and management options for ICIs-P to provide a practice-based global perspective on this disease.

Methods

Five electronic databases were systematically reviewed to identify the relevant studies. Furthermore, we performed a disproportionality analysis utilizing OpenVigil 2.1 to interrogate the United States Food and Drug Administration's Adverse Event Reporting System (FAERS) database.

Results

A total of 61 patients from 58 studies were included in this study. Most patients with ICIs-P were males (60.7%). Most patients received anti-PD-1/PD-L1 monotherapy (78.7%) or anti-PD-1/PD-L1 monotherapy in conjunction with CTLA-4 blockade (19.7%). The median time from the initiation of immune checkpoint inhibitors treatment to pancreatitis was 108 days (range 52-278). Most cases were severe or life-threatening (G3-G4; 64.0%). Corticosteroids were administered to 73.8% of the patients during the treatment of pancreatitis. Regarding treatment outcomes, ICIs-P was reversible in most cases (83.6%), despite the 8.2% relapse and 8.2% deaths. We identified 606 reports of pancreatitis associated with ICIs in the FAERS database, with the greatest proportion of males (50.7%), 62.0% of PD-1 inhibitors, and 22.1% of all reports of death or life-threatening outcomes. Signals indicating pancreatitis were observed across all ICIs, with particular emphasis on Cemiplimab, Pembrolizumab and Nivolumab.

Conclusion

By using a pharmacovigilance database, we discovered an elevated risk of pancreatitis following ICIs therapy, especially with PD-1 inhibitors. Meanwhile, risk factors for ICIs-P remain poorly understood, and diagnosis is challenging. Which may manifest as asymptomatic elevated pancreatic enzyme levels or clinical pancreatitis. Patients with pancreatitis symptoms should have their lipase and amylase levels and radiology evaluated. Diagnosis should be made by excluding other causes. Steroids are the cornerstone of ICIs-P treatment and slow dose reduction is recommended to reduce recurrence.

Retrospective analysis of clinical features of nivolumab-induced immune-related pancreatitis

To study the clinical features of nivolumab-induced immune-related pancreatitis and to provide evidence for its recognition and treatment. Cases of nivolumab-induced pancreatitis were collected by searching Chinese and English databases until November 30, 2024. Forty-three patients were included, with a median age of 61 years (range 23, 79). The median time to onset of pancreatitis was 120 days (range 1, 990) after initial administration. The main symptoms of the patients were abdominal pain (55.8%), nausea (14.0%), vomiting (11.6%), fever (9.3%), anorexia (9.3%), and asymptomatic (7.0%). Laboratory tests showed elevated lipase and amylase levels, with median values of 391.5 IU/L (range 136, 4050) and 1588 IU/L (range 248, 8788), respectively. Pancreatic biopsy showed inflammatory cell infiltration (18.6%), fibrosis (7.0%), and acinar damage and dropout (4.7%). The main imaging findings were focal or diffuse enlargement of the pancreas and fat stranding. After discontinuation of nivolumab and receiving steroid and immunosuppressive therapy (88.4%), patients' symptoms improved at a median time of 42 days (range 7, 192), and 11.6% of patients died. Immune-related pancreatitis should be alert during nivolumab administration. The lack of specificity of clinical symptoms and laboratory tests confuses the diagnosis of pancreatitis. The diagnosis of immune-associated pancreatitis should be treated promptly.

Pancreatic injury in patients treated with immune checkpoint inhibitors: a retrospective multicenterstudy

BACKGROUND

Immune checkpoint inhibitor-related pancreatic injury (ICI-PI) is a rare occurrence, which has not been reported in detail. We conducted a retrospective multicenter study to determine the clinical characteristics, risk factors, and treatment of ICI-PI.

METHODS

We reviewed the medical records of patients who received ICIs for malignant tumors between April 2014 and April 2019 at 16 participating hospitals. Patients with elevated pancreatic enzymes or pancreatitis were identified and classified using the Common terminology Criteria for Adverse Events (CTCAE) ver.5.0). The number of patients with pancreatic enzyme elevation was determined and those with pancreatic enzyme elevation of ≥ grade 3 according to CTCAE ver.5.0, or pancreatitis underwent detailed analysis for ICI-PI.

RESULTS

The study enrolled 1069 patients. Nineteen patients (1.8%) had ICI-PI, 5 (0.5%) of whom also had pancreatitis. Four patients had mild pancreatitis, whereas 1 patient had severe pancreatitis, culminating in death. Steroid therapy was administered to 7 of 19 patients, which led to ICI-PI improvement in 5 patients. On the other hand, ICI-PI improved in 9 of 12 patients who were not administered steroid therapy. Six of the 14 patients with ICI-PI improvement were rechallenged with ICI, and ICI-PI relapse occurred in only 1 patient (16.7%), which improved with ICI discontinuation and steroid therapy.

CONCLUSIONS

ICI-PI is a rare occurrence, with a low incidence of pancreatitis, which followed a very serious course in one patient. Although the benefit of steroid therapy for ICI-PI is unclear, ICI rechallenge is acceptable after improvement of ICI-PI without pancreatitis.

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.

Pembrolizumab-induced Focal Pancreatitis Diagnosed by Endoscopic Ultrasound-guided Fine-needle Aspiration

A 69-year-old man with advanced non-small-cell lung cancer was treated with pembrolizumab for 4 months. Three months after pembrolizumab was discontinued, computed tomography showed enlargement of the pancreatic head, with hypoattenuating areas in the pancreatic head to body. On endoscopic ultrasonography, the entire pancreatic parenchyma was hypoechoic. Endoscopic retrograde cholangiopancreatography showed narrowing of the main pancreatic duct at the pancreatic head. Endoscopic ultrasound-guided fine-needle aspiration showed inflammatory cell infiltration in the stroma but no neoplastic lesions. CD8-positve T cells were dominant over CD4-positive T cells in the infiltrating lymphocytes, and the patient was diagnosed with pembrolizumab-induced pancreatitis.

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.