Title: ATEZOLIZUMAB-INDUCED HYPOPHYSITIS: A RARE COMPLICATION OF PROGRAMMED DEATH LIGAND 1-TARGETED IMMUNOTHERAPY TREATMENT IN SMALL CELL LUNG CANCER
Abstract: SESSION TITLE: Challenging Critical Care CasesSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: Atezolizumab is a second-generation monoclonal antibody that inhibits the programmed death ligand-1 (PD-L1) receptor and is used in the treatment of a variety of cancers, including small and non-small cell lung cancer [1]. PD-L1 inhibitors may rarely cause adverse endocrine events, including hypophysitis [2].CASE PRESENTATION: A 60-year-old Caucasian female came to the emergency department (ED) for a two-week history of progressive dizziness, fatigue, and multiple syncopal episodes resulting in falls. Her medical history was significant for extensive-stage small cell lung cancer on atezolizumab, a prior breast cancer treated with hormone-targeted chemotherapy and radiation, chronic pancreatitis, and occlusive deep vein thrombosis. Clinical examination at ED revealed her to be awake, alert, well oriented, hypotensive (60/40), and hypoglycemic (67 mg/dL) with anorexia. Despite volume resuscitation with three liters of normal saline, she remained hypotensive. Intravenous (IV) vasopressor support was initiated, and she was admitted directly to the intensive care unit for refractory hypotension. Initial evaluation displayed a negative infectious workup, normal renal function, and hemoglobin. Additionally, a transthoracic echocardiogram revealed an intact ejection fraction and normal right ventricular function. Given the persistence of hypotension despite interventions, the patient underwent evaluation for adrenal insufficiency, which yielded a random cortisol level of 0.80 mcg/dL. A cosyntropin stimulation test was performed and confirmed adrenal insufficiency. She was started on stress dose IV hydrocortisone with rapid resolution of her hypotension. The patient was ultimately diagnosed with Atezolizumab Induced Hypophysitis and discharged on a maintenance corticosteroid regimen.DISCUSSION: PD-L1 inhibitors, such as atezolizumab, like other immune checkpoint inhibitors (ICPis), have a well-documented history of endocrinopathies [2]. Specific ICPis have been correlated with specific endocrinopathies. Up to 17.4% of patients treated with ipilimumab, an ICPi that targets CD-152 developed hypophysitis [1]. Atezolizumab induced hypophysitis is often overlooked given its insidious onset and rarity, with a reported incidence of < 1% [3]. Furthermore, the risk of ICPi related endocrinopathies is dose-dependent and is seen more frequently in patients on more than one ICPi [1]. Atezolizumab induced hypophysitis is generally treated with stress dose corticosteroids followed by a taper.CONCLUSIONS: Atezolizumab induced hypophysitis is a rare, potentially life-threatening adverse drug effect that providers need to be cognizant of as it is treatable.Reference #1: González-Rodríguez E, Rodríguez-Abreu D; Spanish Group for Cancer Immuno-Biotherapy (GETICA). Immune Checkpoint Inhibitors: Review and Management of Endocrine Adverse Events. Oncologist. 2016;21(7):804-816. doi:10.1634/theoncologist.2015-0509Reference #2: Chang LS, Barroso-Sousa R, Tolaney SM, Hodi FS, Kaiser UB, Min L. Endocrine Toxicity of Cancer Immunotherapy Targeting Immune Checkpoints. Endocr Rev. 2019;40(1):17-65. doi:10.1210/er.2018-00006Reference #3: Kanie K, Iguchi G, Bando H, et al. Two Cases of Atezolizumab-Induced Hypophysitis. J Endocr Soc. 2017;2(1):91-95. Published 2017 Dec 13. doi:10.1210/js.2017-00414DISCLOSURES: No relevant relationships by Shaili PatelNo relevant relationships by Ish PatelNo relevant relationships by Preet PatelNo relevant relationships by Tarang PatelNo relevant relationships by SACHIN PATIL SESSION TITLE: Challenging Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Atezolizumab is a second-generation monoclonal antibody that inhibits the programmed death ligand-1 (PD-L1) receptor and is used in the treatment of a variety of cancers, including small and non-small cell lung cancer [1]. PD-L1 inhibitors may rarely cause adverse endocrine events, including hypophysitis [2]. CASE PRESENTATION: A 60-year-old Caucasian female came to the emergency department (ED) for a two-week history of progressive dizziness, fatigue, and multiple syncopal episodes resulting in falls. Her medical history was significant for extensive-stage small cell lung cancer on atezolizumab, a prior breast cancer treated with hormone-targeted chemotherapy and radiation, chronic pancreatitis, and occlusive deep vein thrombosis. Clinical examination at ED revealed her to be awake, alert, well oriented, hypotensive (60/40), and hypoglycemic (67 mg/dL) with anorexia. Despite volume resuscitation with three liters of normal saline, she remained hypotensive. Intravenous (IV) vasopressor support was initiated, and she was admitted directly to the intensive care unit for refractory hypotension. Initial evaluation displayed a negative infectious workup, normal renal function, and hemoglobin. Additionally, a transthoracic echocardiogram revealed an intact ejection fraction and normal right ventricular function. Given the persistence of hypotension despite interventions, the patient underwent evaluation for adrenal insufficiency, which yielded a random cortisol level of 0.80 mcg/dL. A cosyntropin stimulation test was performed and confirmed adrenal insufficiency. She was started on stress dose IV hydrocortisone with rapid resolution of her hypotension. The patient was ultimately diagnosed with Atezolizumab Induced Hypophysitis and discharged on a maintenance corticosteroid regimen. DISCUSSION: PD-L1 inhibitors, such as atezolizumab, like other immune checkpoint inhibitors (ICPis), have a well-documented history of endocrinopathies [2]. Specific ICPis have been correlated with specific endocrinopathies. Up to 17.4% of patients treated with ipilimumab, an ICPi that targets CD-152 developed hypophysitis [1]. Atezolizumab induced hypophysitis is often overlooked given its insidious onset and rarity, with a reported incidence of < 1% [3]. Furthermore, the risk of ICPi related endocrinopathies is dose-dependent and is seen more frequently in patients on more than one ICPi [1]. Atezolizumab induced hypophysitis is generally treated with stress dose corticosteroids followed by a taper. CONCLUSIONS: Atezolizumab induced hypophysitis is a rare, potentially life-threatening adverse drug effect that providers need to be cognizant of as it is treatable. Reference #1: González-Rodríguez E, Rodríguez-Abreu D; Spanish Group for Cancer Immuno-Biotherapy (GETICA). Immune Checkpoint Inhibitors: Review and Management of Endocrine Adverse Events. Oncologist. 2016;21(7):804-816. doi:10.1634/theoncologist.2015-0509 Reference #2: Chang LS, Barroso-Sousa R, Tolaney SM, Hodi FS, Kaiser UB, Min L. Endocrine Toxicity of Cancer Immunotherapy Targeting Immune Checkpoints. Endocr Rev. 2019;40(1):17-65. doi:10.1210/er.2018-00006 Reference #3: Kanie K, Iguchi G, Bando H, et al. Two Cases of Atezolizumab-Induced Hypophysitis. J Endocr Soc. 2017;2(1):91-95. Published 2017 Dec 13. doi:10.1210/js.2017-00414 DISCLOSURES: No relevant relationships by Shaili Patel No relevant relationships by Ish Patel No relevant relationships by Preet Patel No relevant relationships by Tarang Patel No relevant relationships by SACHIN PATIL
Publication Year: 2022
Publication Date: 2022-10-01
Language: en
Type: article
Indexed In: ['crossref']
Access and Citation
Cited By Count: 1
AI Researcher Chatbot
Get quick answers to your questions about the article from our AI researcher chatbot