Hilar and Mediastinal Lymphadenopathy Due to Sarcoid-Like Reaction in Patient Receiving Durvalumab
Year: 2021
Type: conference-abstract
Abstract: Immune checkpoint inhibitors (ICPI) downregulate inhibition of the adaptive immune system through blockade of CTLA-4 or PD-1/PD-L1. ICPI are used in numerous malignancies and are associated with favorable treatment responses; however, these medications are associated with immune-related adverse events (irAE). Common irAE include colitis, hepatitis, pneumonitis, and cutaneous manifestations. Uncommon irAE, such as sarcoid-like reactions (SLR), are becoming more prevalent with increasing use of ICPI.A 61 year old woman with a history of stage IIIA lung adenocarcinoma and stage II hepatocellular carcinoma was evaluated for new intrathoracic lymphadenopathy. Her primary malignancies were diagnosed one year prior via biopsies of a PET avid paratracheal lymph node and hepatic mass. She received concurrent chemoradiation and then transitioned to Durvalumab. After 12 cycles of Durvalumab, repeat PET/CT confirmed favorable treatment response; however, imaging also demonstrated new hypermetabolic mediastinal and hilar lymphadenopathy. The patient was asymptomatic at her clinic visit. Vital signs and her exam were unremarkable. Given the results of the PET/CT, she proceeded to an endobronchial ultrasound and had multiple stations sampled. Pathology finalized as granulomatous inflammation without evidence of malignancy, fungal elements, or acid-fast organisms. She was diagnosed with SLR due to ICPI. SLR is defined by the presence of non-caseating granulomas in a patient unable to meet diagnostic criteria for sarcoidosis. SLR has been described for several solid tumors receiving different ICPI. SLR can manifest with pulmonary, cutaneous, and rarely other end-organ manifestations. Onset and presentation of SLR after initiation of ICPI is variable. The management of ICPI SLR includes possible discontinuation of ICPI and/or systemic steroids if the patient is symptomatic. Our patient is the third case report of Durvalumab associated with SLR. A phase 1 trial documented one case of SLR. SLR in the setting of anti-PD-L1 is considered rare as compared to SLR in the setting of other ICPI. The mechanism of SLR in anti-PD-1/PD-L1 therapy remains unclear given paradoxical evidence of sarcoidosis suppression in models of PD-1 blockade. Because our patient was asymptomatic and responding to ICPI therapy, steroid therapy for SLR was deferred and her ICPI was continued. Our case highlights that the differential for PET avid lymph nodes in a patient receiving ICPI is broad and requires tissue sampling. Furthermore, clinicians should keep SLR on the differential for new lymphadenopathy, cutaneous reaction, or end-organ dysfunction for a patient receiving ICPI.
Authors: I. Budnick, J.M. Sturek
Institution: University of Virginia
Language: English
Subfield: Oncology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
OpenAlex ID: W4233324299