Gastrointestinal toxicities of immune checkpoint inhibitors: a multicenter retrospective analysis

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.

Atezolizumab, a PD-L1 Inhibitor: An Association of Bleeding Gastric Ulcer With Its Use

Atezolizumab is a programmed death-ligand 1 inhibitor, an immune checkpoint inhibitor (ICI), useful in various advanced solid malignancies. As atezolizumab is more commonly used nowadays, physicians should be aware of the rare associated adverse events (AEs). Most of the AEs associated with the ICIs are immune-related, and the common gastrointestinal (GI) manifestations are colitis and diarrhea. Upper GI manifestations are rare with atezolizumab, and bleeding gastric ulcer is even rarer. We report here a case of a 62-year-old male with hepatocellular carcinoma who presented with upper GI bleed after atezolizumab therapy. Esophagogastroduodenoscopy showed multiple gastric ulcers, which are likely the cause of his bleeding.