Two different immune related adverse events occured at pancreas after nivolumab in an advanced RCC patient

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 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.

Type 3 autoimmune pancreatitis (immune checkpoint inhibitor-induced pancreatitis)

PURPOSE OF REVIEW

Type 3 auto-immune pancreatitis (AIP) is a rare immune-related adverse event (irAE) because of immune checkpoint inhibitor (ICI) therapy employed in the management of advanced malignancies. The evaluation and management of this disease entity is not well documented in the literature. We summarize the available information on the clinical profile, diagnosis, and treatment of this disorder.

RECENT FINDINGS

ICI-pancreatic injury (ICI-PI) is a form of AIP, recently termed type 3 AIP, which may present as an asymptomatic lipase elevation or clinical pancreatitis, that is, abdominal pain and elevated lipase. CT findings of pancreatitis may be absent in some cases. Diagnosis is based on a temporal relationship to ICI exposure and the absence of other cause of pancreatitis. Combination ICIs increase the risk of type 3 AIP compared with ICI monotherapy. Though corticosteroids are used for ICIP, their role and benefit remain unclear to date. Holding immunotherapy carries the risk of progression of underlying cancer.

SUMMARY

ICI-PI is a unique form of AIP (type 3) with a distinct disease profile. The majority of patients with ICIPI are asymptomatic and steroid therapy has unclear benefits.

Immunoglobulin G4 associated autoimmune cholangitis and pancreatitis following the administration of nivolumab: A case report

BACKGROUND

Immune checkpoint inhibitors have significantly improved survivals for an increasing range of malignancies but at the cost of several immune-related adverse events, the management of which can be challenging due to its mimicry of other autoimmune related disorders such as immunoglobulin G4 (IgG4) related disease when the pancreaticobiliary system is affected. Nivolumab, an IgG4 monoclonal antibody, has been associated with cholangitis and pancreatitis, however its association with IgG4 related disease has not been reported to date.

CASE SUMMARY

We present a case of immune-related pancreatitis and cholangiopathy in a patient who completed treatment with nivolumab for anal squamous cell carcinoma. Patients IgG4 levels was normal on presentation. She responded to steroids but due to concerns for malignant biliary stricture, she opted for surgery, the pathology of which suggested IgG4 related disease.

CONCLUSION

We hypothesize this case of IgG4 related cholangitis and pancreatitis was likely triggered by nivolumab.