Sarcoidosis-like reaction in metastatic triple negative breast cancer treated by anti-PD-L1

PD-L1 expression and tumor-infiltrating lymphocytes: Correlations and prognostic values in Chinese triple-negative breast cancer patients with different molecular subtyping

OBJECTIVE

To investigate the correlation between programmed death ligand-1 (PD-L1) expression and tumor-infiltrating lymphocytes (TILs) and evaluate the prognostic value of PD-L1 and TILs in Chinese triple-negative breast cancer (TNBC) patients with different molecular subtype METHODS: This retrospective study was conducted at 2020. Specifically, the pre-chemotherapy clinical data and non-stained tissue blocks of 465 TNBC patients visited the Fudan University Shanghai Cancer Center (FUSCC) between 2008 and 2014 were collected, with their blocks sliced and stained using PD-L1(SP142), and the outcome of subsequent chemotherapy obtained in 2020. The relapse-free survival (RFS) of the study population was calculated. The baseline PD-L1 expression status correlations with TILs and molecular subtypes were assessed using Spearman's rank correlation analysis and the Kruskal-Wallis test. Kaplan-Meier survival analyses were undertaken to evaluate the prognosis value of TILs and PD-L1 expression.

RESULTS

PD-L1 expression status on IC was moderately and positively correlated with stromal tumor-infiltrating lymphocytes (sTILs) (rs = 0.502, P <0.001) and iTILs (rs = 0.410, P < 0.001), respectively. PD-L1 expression status and TILs showed significant differences among molecular subtypes (P < 0.001), with the highest proportion of PD-L1+ and high TILs patients observed in the immunomodulatory (IM) subtype. TILs were significantly associated with RFS. Moreover, sTILs could act as an independent predictor of RFS (RR 0.953, 95 % CI 0.920 ∼ 0.987, P = 0.007), while PD-L1 expression status did not show the same prognostic significance.

CONCLUSIONS

The incorporation of pre-treatment TILs and PD-L1 expression status as valuable tools for optimizing patient selection for immunotherapy and managing the risks associated with chemotherapy in Chinese TNBC patients.

DATA AVAILABILITY

The data sets generated and analyzed during the current study are available from the corresponding author.

Case Report: Hepatic Sarcoid-Like Reaction Associated With Checkpoint Inhibition in a NSCLC Patient and a Literature Review

Immune checkpoint inhibitor (ICI) treatment has dramatically revolutionized the landscape of therapeutic approaches in multiple cancers, particularly, non-small-cell lung cancer (NSCLC). With the increasing use of programmed death-1 (PD-1) inhibitors in the clinic, the emerging toxicity profile presents a novel learning curve for clinicians. Here we report the first case of an NSCLC patient displaying sarcoid/granulomatous-like reaction (SLR, also known as GLR) in the liver during an anti-PD-1 therapy which showed efficacious response of complete regression. Also, this is the first report describing the SLR induced by toripalimab, a novel PD-1 inhibitor. Given this kind of hepatic findings can be easily mistaken as metastasis, even resulting in premature use of second-line treatments. In particular, we briefly review the clinical features of all those cases reporting sarcoidosis and SLRs manifested on different organs during anti-PD-(L)1 therapy. We anticipate that these clinical cases would help to alert the attention of clinicians that SLRs, as a rare immune-related adverse event (irAE), is manageable and that histopathological analysis is necessary before interpreting it as disease progression.

Atezolizumab-Induced Sarcoidosis-Like Reaction in a Patient with Metastatic Breast Cancer

Tumor-related sarcoidosis-like reactions (SLR) have been reported with the use of immune checkpoint inhibitors (ICIs). We report a case of 50-year-old woman who observed an enlarged lymph node in the right hilar region and the appearance of a subcutaneous mass in the extremities during chemotherapy with atezolizumab plus nab-paclitaxel for metastatic triple-negative breast cancer (TNBC). Skin biopsy revealed the formation of epithelioid granulation species with the Langhans giant cell. After discontinuing atezolizumab in the treatment procedure, the hilar lymph nodes and the subcutaneous mass were reduced. A pathological examination was effective in differentiating tumor exacerbation from SLR. Owing to limited information on ICI-related SLR in breast cancer, future studies are recommended to properly manage immune-related adverse effects during cancer treatment.

Sarcoidosis Induced by Atezolizumab Presenting With Xanthelasma Infiltration

ABSTRACT

Sarcoidosis induced by anti-PD1 or anti-PDL1 agents such as atezolizumab has recently been reported. It has been suggested that the predilection of sarcoidosis to affect scars is due to the presence of antigens or foreign bodies that can serve as a stimulus for granuloma formation. However, to the best of our knowledge, sarcoidosis-specific skin lesions have not to date been reported involving xanthelasma. We report a patient who developed specific lesions of sarcoidosis infiltrating some xanthelasmata 6 months after starting treatment with atezolizumab. A 69-year-old woman was referred to the dermatology department for infiltration of xanthelasmata. The patient was being treated with atezolizumab for metastatic uterine carcinosarcoma. Cutaneous biopsy from an infiltrated xanthelasma and from still yellow, no infiltrated xanthelasma showed differing proportions of foamy histiocytes and sarcoid granulomas. On physical examination, erythemato-marronaceous papules clustered on both knees, and not previously detected by the patient, were observed. The biopsy showed sarcoid dermal granulomas with foreign bodies. A chest computerized tomography scan was consistent with intrathoracic involvement of sarcoidosis. Endobronchial ultrasound-guided transbronchial needle aspiration of a mediastinal lymphadenopathy showed epithelioid cell granulomas. Histopathologically, the foamy histiocytes of xanthelasma seem to be replaced by or evolve to epithelioid cells to form sarcoid granulomas. The possible pathogenic mechanism is discussed. Dermatologists and dermatopathologists should bear in mind that sarcoidosis can present as infiltration of pre-existing xanthelasmata.

Sarcoid-like reaction in cases treated by checkpoint inhibitors

Sarcoidosis is a multisystem granulomatous disorder characterized by helper T cell inflammation. Sarcoid-like reaction (SLR) is a well-defined entity and may be related with several malignant disorders and/or their therapies. SLR has been reported more than 20 years ago and in recent years in cases treated by checkpoint inhibitors (CPIs). Better outcome has been reported in cases developing granulomatous reaction and/or SLRs during CPI treatments. However, these lesions clinically may be thought as disease progression and may cause to stop treatment or alterations. These therapeutic manipulations may be harmful for the patients. Clinicians should be aware of SLRs in cases treated by CPIs and tissues must be sampled and reviewed by an experienced pathologist to avoid misdiagnosis and also unnecessary CPI treatment cessations.Significance StatementClinicians should be aware of sarcoid-like reactions in cases treated by checkpoint inhibitors and tissues must be sampled and reviewed by an experienced pathologist to avoid misdiagnosis and CPI treatment stops.

Sarcoidosis-like reactions in cancer patients treated with immune checkpoint inhibitors: experience in a Spanish hospital

BACKGROUND

Immune checkpoint inhibitors (ICI) have been associated with several immune-related adverse events, including sarcoidosis-like reactions (SLR). SLR, which has a low prevalence but an increasing incidence, is similar to sarcoidosis in terms of histology, and clinical and radiological manifestations. The most commonly affected organs are hilar and mediastinal lymph nodes and skin. SLR is an exclusion diagnosis, so a lymph node biopsy can be useful to distinguish between tumor progression and SLR, particularly in tumors in which nodal involvement is very common.

PATIENTS AND METHODS

We performed a retrospective analysis of SLR in all cancer patients receiving ICIs in our institution between January 2016 and June 2020.

RESULTS

Among the 1063 treated patients, seven experienced SLR, four of whom were symptomatic (cough, skin lesions, arthralgia), with time to onset ranging from 1.5 to 6.7 months after ICI initiation. All seven patients had bilateral hilar lymphadenopathy, and granulomatous reactions in five of the six patients with lymph node biopsies. SLR improved in all patients, including four patients who continued with ICI. Three patients received corticosteroids and/or stopped ICI therapy. Four of these patients had partial responses at the time SLR was identified.

CONCLUSION

Management of SLR lacks a consensus recommendation, although corticosteroids and/or stopping the ICI are generally implemented. The potential consequences of stopping anticancer treatment should be taken into consideration, particularly in the absence of clear management recommendations.

Sarcoidosis-like reaction during palbociclib treatment for metastatic breast cancer: A case report

This case report describes a 62-year-old female patient developing a granulomatous sarcoidosis-like reaction in mediastinal lymphatic nodes during a treatment by palbociclib for a metastatic breast carcinoma. After a 3-month treatment associating palbociclib, anastrozole, denosumab, and a single targeted cervical vertebral metastasis radiation therapy, a positron emission tomography showed full regression of breast, vertebral, and axillary node lesion contrasting to new emergent metabolic mediastinal lymph nodes. An endobronchial ultrasound-guided transbronchial needle aspiration revealed a sarcoidosis-like reaction, which dramatically decreased with glucocorticoids.