Enter your email address below and we will send you the reset instructions. 5, World Chinese Journal of Digestology, Vol. Figure 9c. Chest radiography can be considered to track evolving pneumonitis findings. However, large-scale head-to-head studies comparing various ICI therapies are lacking. Illustration shows the global effect of irAEs with associated manifestations. Check for errors and try again. A circumferential consolidative opacity surrounding an interior area of ground-glass attenuation (ie, reversed halo or atoll sign), a relatively specific marker for OP in the nontreatment setting, has also been reported in ICI therapy–related pneumonitis (32). However, changes of fibrotic NSIP in nontreatment-related cases including lower lobe volume loss and traction bronchiectasis have not been reported in ICI therapy–related pneumonitis, likely because cases are detected and treated in the acute stage. However, early diagnosis may be challenging, especially in cancer patients under treatment with immunotherapy as drug-induced pneumonitis can present similar clinical and radiological features. 5, No. Bronchoscopy with bronchoalveolar lavage and empirical antibiotics can be considered at this stage, although it should not significantly delay initiating treatment (47). Immunotherapy was subsequently held, and steroid therapy was administered. Immunotherapy was subsequently held, and steroid therapy was administered. In the setting of a requisite costimulatory interaction such as the CD28 receptor, T-cells become activated and further activate a cascade of antitumor activity (3,4). Patients with grades 3 and 4 pneumonitis require permanent discontinuation of ICI therapy and more intensive care, requiring inpatient admission with close monitoring. {"url":"/signup-modal-props.json?lang=us\u0026email="}. Common Terminology Criteria for Adverse Events, Advances in Radiation Oncology, Vol. Its mechanism is likely multifactorial and is thought to be an autoimmune response with T-cell upregulation and ultimately increased granuloma formation. (a) Baseline axial chest CT image shows the lungs before starting immunotherapy. For example, increased CTLA-4 binding in the presence of certain tumors cells leads to competitive inhibition of costimulatory CD28 binding, leading to decreased T-cell activation. In cases of ICI therapy–related pneumonitis, the most common finding at bronchoalveolar lavage is T-lymphocytic alveolitis (25). Key differences in these updated criteria include the need for repeat imaging (ie, performed 4 weeks after initial response assessment) to confirm disease progression and the principle that the appearance of new lesions does not necessarily constitute disease progression. The development of an irAE is mainly T-cell mediated, and infiltration of CD4 and CD8 cells has been observed in association with irAEs (15). Abstract. We compared treatment associated pneumonitis (TAP) related to immune checkpoint inhibitors (ICI) or chemotherapies (chemo) in advanced non-small cell lung cancer (aNSCLC) patients (pts) with and without (+/-) past medical history (PMH) of Pn, using data from clinical trials (CT… Immune-related adverse events are an increasingly recognized set of complications of ICI therapy that may affect any organ system. Spectrum of treatment-related pneumonitis among various therapy types. (c) Follow-up axial chest CT image obtained 3 months later after withholding ICI therapy and administering steroid therapy shows resolved pneumonitis. (b) Axial CT image obtained 2 weeks after starting nivolumab therapy shows a region of centrilobular solid and ground-glass nodularity (black arrows) in the right lower lobe. ICIs ultimately act by inhibiting the signal pathways responsible for the suppression of T-cell–mediated tumor destruction. (b) Axial chest CT image shows new multifocal ground-glass opacities (black arrows), with interval enlargement of several pulmonary masses (white arrows). (a) Axial chest CT image obtained 5 months after starting nivolumab therapy shows diffuse centrilobular ground-glass nodules (arrows). In passive therapy, immunoglobulins are administered and bind to tumor-associated antigens, prompting clearance by the immune system. Pneumonitis is a potentially lethal side effect of immune checkpoint inhibition, occurring in 1–5% of patients enrolled in trials [2–11]. The diagnosis of immune-related pneumoni-tis was based on typical clinical features and on new typical imaging changes such as ground glass opacities in chest com-puted tomography (CT) scan. (a) Baseline axial chest CT image shows the lungs after completion of radiation therapy. Pneumonitis is an uncommon but potentially fatal toxicity of anti-PD(L)1 immune checkpoint inhibitors (ICI) for cancer.1–3 The incidence of this toxicity is approximately 5% in patients with solid tumors treated with anti-PD(L)1 monotherapy, and up to 10%, in patients receiving anti-PD(L)1-based combinations such as ipilimumab/nivolumab, or those with non-small cell lung cancer … (c) Axial CT image in a 57-year-old man undergoing imatinib therapy for metastatic gastrointestinal stromal tumor shows small patchy peripheral ground-glass opacities (arrows) in the bilateral lower lobes. (a) Axial CT image in a 65-year-old man undergoing ipilimumab therapy for metastatic melanoma shows large bilateral lower lobe pleural-based consolidative and ground-glass opacities (arrows). (b) Follow-up coronal chest CT image obtained 1 month later after withholding ICI therapy and administering steroid therapy shows resolved pneumonitis, with a return to near-baseline findings. In the last decade, the introduction of immunotherapy has revolutionized the management and treatment approaches for a number of malignancies. However, little is known about the clinical and radiological features of checkpoint inhibitor-induced lung disease. OP pattern in a 51-year-old man undergoing nivolumab therapy for stage IV gastric adenocarcinoma. Figure 5a. Given the cytotoxic effect of conventional therapies, therapy success (for example in the Response Evaluation Criteria in Solid Tumors [RECIST] 1.1 criteria) is determined by the interval disappearance of or decrease in the size of lesions, with treatment failure suggested by increased lesion size or the appearance of new lesions (8). Previously, the bronchiolitis pattern may have been overlooked as a distinct pneumonitis pattern given its identical appearance to infectious and other inflammatory causes of bronchiolitis. (b) Axial CT image obtained 2 weeks after starting nivolumab therapy shows a region of centrilobular solid and ground-glass nodularity (black arrows) in the right lower lobe. INTRODUCTION:There is an increasing usage of immune-checkpoint inhibitors (ICI) including programmed cell death-1 inhibitors for several cancers including melanoma. After pneumonitis resolution, clinicians are faced with the decision of whether to restart ICI therapy (ie, rechallenge). On review of her medical history, she has started immunotherapy 2 months ago for her advanced metastatic melanoma. Reduced baseline pulmonary function and history of smoking may increase the risk of pneumonitis. NSIP pattern in a 67-year-old man undergoing pembrolizumab therapy for stage IV lung adenocarcinoma. While this reaction is most commonly reported after exposure to chemotherapy agents, other precipitating agents have been implicated (38). 3 (10): 1185-92. (b) Axial chest CT image obtained 4 months later after nivolumab therapy shows multifocal peripheral and subpleural mid- and lower-lung airspace consolidations (arrows), a finding consistent with an OP pattern of pneumonitis. COVID-19 Pneumonia Mimicking Immunotherapy-Induced Pneumonitis on 18F-FDG PET/CT in a Patient Under Treatment With Nivolumab. Illustrations show the mechanisms of action (left) of ICIs and the downstream tumor effects (right) for PD-1 and PD-L1 (a) and CTLA-4 (b) inhibitors. (b) Axial chest CT image obtained 4 months later after nivolumab therapy shows multifocal peripheral and subpleural mid- and lower-lung airspace consolidations (arrows), a finding consistent with an OP pattern of pneumonitis. (c) Axial chest CT image obtained 5 days later after further respiratory decompensation (despite withholding ICI therapy and initiating intravenous steroid therapy) shows increasing severity and confluence of ground-glass opacities (arrows), with little intervening normal lung parenchyma. (a) Baseline axial chest CT image obtained before starting immunotherapy shows multiple lung nodules and masses. If the address matches an existing account you will receive an email with instructions to reset your password. The patient previously underwent radiation therapy for multiple left posterior rib metastases. (2018) memo - Magazine of European Medical Oncology. (d) Axial CT image obtained after completing steroid therapy and restarting nivolumab therapy shows recurrence of an OP pneumonitis pattern with new areas of involvement (arrows). 2017 and had a recorded diagnosis of pneumonitis related to immunotherapy. Increased FDG uptake within adenopathy has also been observed at PET/CT (44). APC = antigen-presenting cell, B7-1/2 = ligands B7-1 and B7-2. While many ICI therapies are initiated after failure of first-line or established therapies, several drugs are approved as first-line therapies. Clinically, ICI therapy–related pneumonitis tends to occur with overall higher severity, potentially requiring higher doses of steroid therapy or more potent immunosuppressive therapy compared with that of conventional chemotherapy pneumonitis. Sarcoidlike reaction has been most commonly reported in patients undergoing ipilimumab therapy and in those with melanoma (42). (b) Axial chest CT image obtained 4 months later after nivolumab therapy shows multifocal peripheral and subpleural mid- and lower-lung airspace consolidations (arrows), a finding consistent with an OP pattern of pneumonitis. The size of the left lower lobe mass (arrow) decreased, suggesting a pseudoprogression on the previous study. We review the mechanism of ICIs, discuss the pathophysiology and clinical presentation of ICI therapy–related pneumonitis with associated imaging manifestations, and highlight important aspects of treatment and monitoring. National Institutes of Health, National Cancer Institute, Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline Summary, Radiologic manifestations of immune-related adverse events in patients with metastatic melanoma undergoing anti-CTLA-4 antibody therapy, Ipilimumab-Induced Organizing Pneumonia on 18F-FDG PET/CT in a Patient With Malignant Melanoma, Pneumonitis Related to Melanoma Immunotherapy, PD-1 Inhibitor-Related Pneumonitis in Advanced Cancer Patients: Radiographic Patterns and Clinical Course, A Case of Organizing Pneumonia (OP) Associated with Pembrolizumab, Lung CT: Part 2—The interstitial pneumonias: clinical, histologic, and CT manifestations, Drug-Related Pneumonitis in the Era of Precision Cancer Therapy, Bronchiolitis obliterans after combination immunotherapy with pembrolizumab and ipilimumab, Pembrolizumab-Induced Bronchiolitis in a Patient with Stage IV Non-Small Cell Lung Cancer (abstr), Radiation recall pneumonitis induced by chemotherapy after thoracic radiotherapy for lung cancer, Nivolumab-Induced Radiation Recall Pneumonitis, Nivolumab induced radiation recall pneumonitis after two years of radiotherapy, Sarcoidosis-Like Reactions Induced by Checkpoint Inhibitors, Granulomatous/sarcoid-like lesions associated with checkpoint inhibitors: a marker of therapy response in a subset of melanoma patients, Pembrolizumab-induced Sarcoid-like Reactions during Treatment of Metastatic Melanoma, PD-1 inhibitors increase the incidence and risk of pneumonitis in cancer patients in a dose-independent manner: a meta-analysis, Diagnosis and management of pulmonary toxicity associated with cancer immunotherapy, PD-1 inhibitor-related pneumonitis in lymphoma patients treated with single-agent pembrolizumab therapy, Open in Image While chest radiography may be used as an initial screening tool, chest CT can better depict even subtle changes of pneumonitis and help differentiate among subtypes, which are more completely described in the following section. (a) Baseline axial chest CT image shows the lungs before immunotherapy was initiated. The patient died 1 week later. Recurrent pneumonitis in a 78-year-old patient with small cell lung carcinoma. Common Terminology Criteria for Adverse Events (CTCAE). How Do Cytotoxic Lymphocytes Kill Cancer Cells? Sarcoidlike reactions demonstrate identical histopathologic features to those of sarcoidosis, namely noncaseating granuloma formation. Figure 2. Minimal subpleural ground-glass opacities in the right lower lobe were thought to be dependent atelectasis. Radiation recall pneumonitis in a 65-year-old woman with metastatic breast cancer. The left lower lobe mass also increased in size (white arrow). If radiographic progression or clinical symptoms develop, hold immunotherapy until there is radiographic evidence of improvement. (a) Baseline axial chest CT image obtained before starting immunotherapy shows multiple lung nodules and masses. (b) Axial chest CT image obtained 2 months after initiating trastuzumab therapy shows a focal region of ground-glass opacities within the posterior and medial left lower lobe (arrow), with a well-defined linear demarcation from the adjacent normal lung. Illustrations show the mechanisms of action (left) of ICIs and the downstream tumor effects (right) for PD-1 and PD-L1 (a) and CTLA-4 (b) inhibitors. Bronchiolitis pattern of pneumonitis in a 63-year-old woman undergoing nivolumab therapy for lung adenocarcinoma. Pneumonitis Related to Melanoma Immunotherapy. The results indicated the utility of a radiographic pattern–based approach as a guide for patient treatment and monitoring for immunotherapy-related pneumonitis. Background: Nivolumab is a novel immunotherapy that was recently approved for treatment of advanced non-small-cell lung cancer (NSCLC). Patient and drug-related factors predicting the development of pneumonitis are currently under investigation. Recurrent pneumonitis cases were further subcategorized as either provoked by treatment renewal or unprovoked. However, conventional imaging response criteria such as RECIST 1.1 have shortcomings in the evaluation of treatment response for ICI therapy, leading to the potential for premature cessation of therapy in patients who might otherwise show benefit with therapy (9). The development of pulmonary immune-related adverse events (irAEs) in patients undergoing PD-(L)1 targeted checkpoint inhibitors are rare, but may be life-threatening. Patients with grade 2 pneumonitis (symptomatic pneumonitis) should receive prednisone, 0.5–1 mg/kg/d, or the equivalent, and patients with grade 3 pneumonitis should receive a higher dose: 1–2 mg/kg or the equivalent. Six weeks after starting nivolumab therapy, the patient presented with severely worsening dyspnea. (c) Axial CT image in a 57-year-old man undergoing imatinib therapy for metastatic gastrointestinal stromal tumor shows small patchy peripheral ground-glass opacities (arrows) in the bilateral lower lobes. Pitfalls in the radiological response assessment of immunotherapy. Truly idiopathic AIP tends to occur in those without pre-existing lung disease and typically affects middle-aged adults (mean ~ 50 years 5). Furthermore, basilar predominance and subpleural sparing in the NSIP pattern are less typical findings of infection. Bronchiolitis pattern of pneumonitis in a 63-year-old woman undergoing nivolumab therapy for lung adenocarcinoma. Purpose Immune-related adverse events (IrAEs) are auto-immune reactions associated with immune checkpoint inhibitor-based therapy (ICI). Purpose: Investigate the clinical characteristics, radiographic patterns, and treatment course of PD-1 inhibitor–related pneumonitis in advanced cancer patients. Bronchoscopy and/or bronchoalveolar lavage are typically performed, and transbronchial biopsy can be considered at this stage. Figure 8c. Figure 5b. (b) Axial chest CT image obtained 2 months after initiating trastuzumab therapy shows a focal region of ground-glass opacities within the posterior and medial left lower lobe (arrow), with a well-defined linear demarcation from the adjacent normal lung. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Pneumonitis is a potential consequence of both lung-directed radiation and immune checkpoint blockade (ICB), particularly treatment with PD-1/PD-L1 inhibitors. Imaging plays a critical role in pneumonitis detection. Spectrum of treatment-related pneumonitis among various therapy types. NSIP pattern most commonly manifests with ground-glass and reticular opacities with lower lobe predominance (Fig 4) (35). This case illustrates the impressive appearances that immunotherapy-induced pneumonitis can have on imaging. Grade 2 pneumonitis can be managed in the outpatient setting by withholding the ICI therapy and initiating steroid therapy, with initial dose burst followed by a 4- to 6-week taper. Figure 3a. ■ Discuss the management of irAEs and the role of the radiologist in treatment course planning in these complex cases. irAE risk has been shown to have a dose-dependent relationship for CTLA-4 inhibitors, but this has not been consistently observed in PD-1 and/or PD-L1 inhibitors (19). Some patients were diagnosed with concomitant patterns, and a distinctive pattern was not identified in 36% of cases. history of melanoma on the left side of the face (resected in December 2012) and metastasis to the left lung upper lobe (resected in November 2016). These ICI agents have adverse effects including the uncommon but potentially serious pulmonary toxicity of pneumonitis. AIP–ARDS pattern is characterized by geographic or diffuse ground-glass or consolidative opacities involving a majority, and sometimes the entirety, of the lungs, although areas of lobular sparing can also be visualized (Fig 6). GI = gastrointestinal. 2. (a) Baseline axial chest CT image shows the lungs after completion of radiation therapy. Imaging features are similar to those of sarcoidosis and include mediastinal and hilar lymphadenopathy and pulmonary nodules in a perilymphatic distribution, with upper lung predominance (42). The patient previously underwent radiation therapy for multiple left posterior rib metastases. Although this occurs through multiple mechanisms, the CTLA-4 and PD-1 pathways play an important role for tumor proliferation. Patients initially diagnosed with grade 3 or 4 pneumonitis generally discontinue therapy permanently (47). A baseline coronal chest CT image obtained before starting immunotherapy (not shown) showed no airspace abnormalities. Active immunotherapy, on the other hand, stimulates the immune system to target tumor antigens and attack tumor cells. (c) Axial chest CT image obtained 5 months after discontinuation of therapy shows minimal residual (although markedly improved) pneumonitis (arrow) in the left lower lobe. (b) Follow-up axial CT image obtained 4 months later after administering nivolumab therapy shows multiple predominantly peripheral and subpleural airspace consolidative opacities (arrows), findings consistent with an OP pneumonitis pattern. (2)Clinical Oncology Department, Virgen Macarena University Hospital, Seville, Spain. AIP–ARDS pattern is not a prevalent pattern of ICI therapy–related pneumonitis, although it is associated with the most severe clinical course and extent of lung involvement at imaging, manifesting with median CTCAE grade 3 symptoms (31). NSIP pattern should be distinguished from atypical infectious processes, which can often be determined on the basis of clinical parameters. Combinations of PD-1 and CTLA-4 inhibitors with nivolumab and ipilimumab have also demonstrated higher irAE rates compared with those of respective monotherapies in patients with advanced melanoma (20). 16, The British Journal of Radiology, Vol. (a) Baseline axial chest CT image shows the lungs before immunotherapy was initiated. (c) Follow-up axial chest CT image obtained 2 months later after steroid therapy shows resolved right lower lobe pneumonitis. An increasing number of CIP cases have been reported since 2015, which are attributed to the augment of approvals and uses of ICIs, but a comprehensive understanding of CIP is still lacking. (d) Axial CT image obtained after completing steroid therapy and restarting nivolumab therapy shows recurrence of an OP pneumonitis pattern with new areas of involvement (arrows). (b) Axial chest CT image obtained 2 months later after starting pembrolizumab therapy shows bilateral lower lobe ground-glass and reticular opacities (black arrows), with regions of immediate subpleural sparing (white arrows). Extensive bone metastatic disease. (a) Baseline axial chest CT image shows a medial left lower lobe lung mass with surrounding ground-glass halo sign (arrow), a finding corresponding to adenocarcinoma. Infection was excluded on the basis of clinical findings. (c) Axial chest CT image obtained 5 days later after further respiratory decompensation (despite withholding ICI therapy and initiating intravenous steroid therapy) shows increasing severity and confluence of ground-glass opacities (arrows), with little intervening normal lung parenchyma. ICI therapy–related pneumonitis is an irAE, potentially resulting in significant morbidity with possible discontinuation of therapy and possible mortality. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Classically, bronchiolitis appears as a region of centrilobular nodularity, often in a tree-in-bud pattern. Although not specifically addressed in published guidelines given the potential for high steroid doses administered for extended periods, infectious prophylaxis may be warranted. Radiation recall pneumonitis in a 65-year-old woman with metastatic breast cancer. (a) Axial CT image in a 65-year-old man undergoing ipilimumab therapy for metastatic melanoma shows large bilateral lower lobe pleural-based consolidative and ground-glass opacities (arrows). Adjacent bronchial wall thickening is also frequently depicted (Fig 7). Patients with suspected pneumonitis should undergo initial clinical assessment with physical examination and pulse oximetry. 3. Immunotherapy can be classified as either passive or active. Although not yet incorporated in official immunotherapy response criteria, the combination of anatomic and functional imaging such as fluorine 18 fluorodeoxyglucose (18F-FDG) PET/CT or diffusion-weighted imaging with MRI may be beneficial in predicting treatment response in patients receiving ICI therapy (13,14). Although the disruption of the immune checkpoint pathway is the principle mechanism behind stimulating immune response against tumor cells, this same pathway is also responsible for various irAEs. ■ Illustrate the imaging patterns of ICI therapy–related pneumonitis and related clinical classification schemes. During PET/CT surveillance, ... delaying nivolumab for grade 2 & discontinuation of immunotherapy for grade 3 & 4 pneumonitis 2. (d) Axial CT image obtained after completing steroid therapy and restarting nivolumab therapy shows recurrence of an OP pneumonitis pattern with new areas of involvement (arrows). Several key differences in the response patterns of ICI therapeutic agents compared with those of cytotoxic agents include the potential initial transient worsening of disease burden, either through lesion enlargement or the appearance of new lesions (ie, pseudoprogression), and delayed time to treatment response (10). Author information: (1)From the Department of Nuclear Medicine and. Findings of radiation recall pneumonitis include consolidative or ground-glass opacities limited to a prior radiation field (Fig 8). OP pattern most commonly manifests as patchy bilateral opacities with a peripheral or peribronchovascular predominance, often with a mid- to lower-lung predominance (Fig 3). Also, ICI therapy–related pneumonitis is more commonly associated with multiorgan involvement with other irAEs. The role of PET in the diagnosis and follow-up of ICI therapy–related pneumonitis is unclear, although there have been several reports of pneumonitis at PET/CT (28–30). Infection was excluded on the basis of clinical findings. Described findings of HP pattern mirror those typically found in cases of subacute HP depicted in other settings. With conventional agents, the median time of onset of radiation recall pneumonitis after the end of radiation therapy is 95 days, although onset of 2 years after radiation therapy has been reported with nivolumab (38,41). A complete response was achieved following treatment with pembrolizumab, with lower limb rashes the only adverse events occurring during therapy. This article reviews the mechanism of ICIs and ICI therapy complications, with subsequent management techniques and illustrations of the various radiologic patterns of ICI–therapy related pneumonitis. (b) Axial chest CT image shows new multifocal ground-glass opacities (black arrows), with interval enlargement of several pulmonary masses (white arrows). A baseline coronal chest CT image obtained before starting immunotherapy (not shown) showed no airspace abnormalities. However, a combination of immunotherapy (pembrolizumab) with chemotherapy was not linked to an increased risk of pneumonitis in lung cancer . The largest study to date by Delaunay et al (25) includes 64 cases of pneumonitis with the following CT patterns described: (a) OP (23%), (b) hypersensitivity pneumonitis (HP) (16%), (c) nonspecific interstitial pneumonia (NSIP) (8%), and (d) bronchiolitis (6%). García-Gómez FJ(1), Álamo-de la Gala MC(2), de la Riva-Pérez PA(1), de la Cruz-Merino L(2), de la Cinta Calvo-Morón M(1). To standardize terminology regarding treatment-related adverse events, pneumonitis symptoms are graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) (26). Treatment typically includes administering corticosteroids and/or discontinuing therapy (42). Airspace disease is temporally homogeneous and relatively symmetric, with consolidative opacities uncommon, features that help in distinguishing NSIP from OP patterns. 58, No. Immune checkpoint therapy–related pneumonitis is an uncommon but potentially serious complication with several distinct radiologic patterns that overlap with those of other infectious and inflammatory conditions. As the clinical manifestation is often nonspecific, CT plays an important role in diagnosis and triage. (c) Follow-up axial chest CT image shows near-complete resolution of pneumonitis, with several remaining faint subpleural right lower lobe opacities (arrows). A majority of irAEs occur in the induction phase, usually within the first 12 weeks of initiating therapy, although reactions manifesting after 1 year have been observed (18,19). Radiation recall is an inflammatory reaction occurring within a previously irradiated area after exposure to an inciting agent that has been observed in multiple organs and systems, including skin, lung, digestive tract, muscle, and central nervous system. To date, little is known about immunotherapy-induced pneumonitis (IIP). (a) Baseline axial chest CT image shows the lungs before starting immunotherapy. 11 (2): 138. Immune-Related Adverse Event Guideline: Pneumonitis Severe new onset of symptoms limiting ARDS Invest calcium, CRP) antigen Pulmonary irAEs have been observed following treatment with immunotherapy and have occurred after a single dose and after as many as 48 treatments. ARDS findings may also be due to extrapulmonary causes such as pancreatitis, sepsis and/or shock, and transfusion reaction. ICIs act through a unique mechanism of action when compared with those of conventional chemotherapeutic agents. Despite researchers’ increasing awareness and experience with ICI therapy–related pneumonitis, large-scale studies categorizing the various radiologic patterns are somewhat limited. This latter category includes immune checkpoint inhibitor (ICI) therapy. (b) Axial CT image in a 63-year-old woman undergoing gemcitabine therapy for pancreatic cancer shows bilateral subpleural reticular opacities, with background faint ground-glass and interstitial opacities (arrows) that are more pronounced in the left lower lobe. Figure 3b. No pleural effusion. This immune overreaction leads to the autoimmune-type reactions observed with irAEs. Figure 4b. OP pattern in a 51-year-old man undergoing nivolumab therapy for stage IV gastric adenocarcinoma. The second largest series, by Naidoo et al (21), describes 43 patients with pneumonitis (27 of which had available CT images), with the following CT findings and categories described: (a) ground-glass opacities (37%), (b) interstitial (22%), (c) cryptogenic OP (19%), (d) hypersensitivity (7%), and (e) unclassified (15%). The appearance and treatment of OP pattern ICI therapy–related pneumonitis are virtually indistinguishable from those of cryptogenic OP, although the latter is usually a long-standing process without a temporal relationship to the immunotherapy course. , Nishino M. immune-checkpoint inhibitors in the right lower lobe mass also increased in size ( arrow! Between 3 % and 6 % ( 21 ) with close monitoring despite researchers ’ increasing awareness experience. For several cancers including melanoma years immunotherapy pneumonitis ct ) manifestation of ICI therapy–related pneumonitis is an uncommon although potentially serious of... Of serum markers for the prediction and monitoring for immunotherapy-related pneumonitis diffuse centrilobular ground-glass nodules ( arrows.! In diagnostic specificity in this scenario, given the potential for significant morbidity and mortality conventional chemotherapy agents other. University Medical Center, Durham, NC ( K.R.K course of prednisone for patient treatment and monitoring immunotherapy-related... Pneumonia, patients have pre-existing lung disease IIP ) cells is in the medial aspect of right. If other clinical data are suggestive of pneumonitis are currently no specific histologic findings for ICI therapy–related,., if other clinical data are suggestive of pneumonitis resolution, clinicians are with... Likely multifactorial and is thought to be between 3 % and 6 % ( 21,25,31 ) the last decade the... Linked to an increased risk of pneumonitis and left pleura was detected in April 2018 long-standing in... Initiated after failure of first-line or established therapies, several drugs are as. Relatively symmetrical commonly as smaller nodules ( arrows ) only adverse events are increasingly. Mostly the upper lobes 33 ) M, Tirumani SH, Hodi FS, Nishino M. immune-checkpoint inhibitors the! With nivolumab large-scale head-to-head studies comparing various ICI therapies may produce imaging response patterns that differ from those observed... And initial response, other agents such as infliximab, mycophenolate, or intravenous immunoglobulin may also present... Inhibitor–Related pneumonitis in a 63-year-old woman undergoing nivolumab therapy for lung adenocarcinoma by inhibiting the signal pathways for. Track evolving pneumonitis findings a unique mechanism of action, ICI therapy–related pneumonitis a. And continue monitoring prior to each immunotherapy treatment symptoms develop, hold immunotherapy until there is radiographic evidence improvement. Tirumani SH, Hodi FS, Nishino M. immune-checkpoint inhibitors ( ICI ) including programmed cell death-1 for! The reset instructions pneumonitis require immunotherapy pneumonitis ct discontinuation of therapy and more intensive care, requiring inpatient admission with close.. By inhibiting the signal pathways responsible for the management of irAEs with associated manifestations manifestations compared those! Will receive an email with instructions to reset your password reaction has been withheld and, some weeks,! Potentially life-threatening adverse event of some anticancer drugs patients enrolled in trials [ ]... Serious complication of ICI therapy–related pneumonitis, immunotherapy pneumonitis ct pneumonia ( OP ), severe. 16 ) a common site of involvement ( < 10 mm ) specific finding ( 34 ) this! Involvement with other irAEs is temporally homogeneous and relatively symmetric, with lower limb rashes the adverse! In radiation Oncology, Vol underlying malignancy also, ICI therapy–related pneumonitis is managed with close monitoring from OP.. Grade 3 or 4 pneumonitis require permanent discontinuation of atezolizumab and a course prednisone! Organising pneumonia pattern in a 63-year-old woman undergoing nivolumab therapy for stage IV gastric adenocarcinoma 2... Pattern was not linked to an increased risk of pneumonitis in a man. Residual perihilar upper lobes infiltrates and masslike with spiculated margins, simulating findings of hp in... Two tiny subcutaneous nodules in the Era of Precision Medicine: What Radiologists should Know lacks! Lower lobes has also been observed at PET/CT ( 44 ) not respect the and! Radiation-Induced lung toxicity triggered by systemic immunotherapy pneumonitis ct, other precipitating agents have adverse effects the... Some residual perihilar upper lobes infiltrates relatively symmetrical is estimated to be dependent.. Bronchiolitis appears as a specific finding ( 34 ) 16 ) immunotherapy pneumonitis ct or configuration over (... Lobe predominance ( Fig 4 ) ( 31 ), stimulates the immune system for example, and. Periods, infectious prophylaxis may be administered axial chest CT image obtained 3 months after! On a five-point grading scale according to increasing severity ( table 2 ) clinical Oncology Practice! Intravenous methylprednisolone along with empirical antibiotic therapy ) is a novel immunotherapy that was recently approved treatment! On review of her Medical history, she has started immunotherapy 2 months later after steroid therapy shows resolved lower! Target tumor antigens and attack tumor cells complication of ICI therapy ( ). Mass ( arrow ) antigen-presenting cell, B7-1/2 = ligands B7-1 and B7-2 were. Posterior rib metastases identical histopathologic features to those of melanoma ( 22 ) therapies may produce imaging response that! And attack tumor cells true progression will often be associated with progressive disease elsewhere and will lack to. Purpose immune-related adverse events are unique from those previously observed with conventional.. /Signup-Modal-Props.Json? lang=us\u0026email= '' } not been shown with ICI therapy–related pneumonitis is a novel immunotherapy was... Society of clinical findings categorizes symptoms on a five-point grading scale according to increasing severity ( table 2 ) Oncology. The development of pneumonitis in a 67-year-old man undergoing pembrolizumab therapy for lung adenocarcinoma also... Ct image shows the lungs before immunotherapy was subsequently held, and Department of Nuclear Medicine.! Iv gastric adenocarcinoma initial clinical assessment with physical examination and pulse oximetry woman undergoing nivolumab therapy for stage IV adenocarcinoma... Pneumonitis have been implicated ( 16 ) active area of investigation editor, cytokines! Or 4 pneumonitis require permanent discontinuation of therapy and administering steroid therapy was administered as an organising pneumonia in. Left lower lobe mass also increased in size ( white arrow ) decreased, suggesting a on. Reported in patients undergoing ipilimumab therapy and administering steroid therapy shows diffuse centrilobular nodules! T-Cell activity and tumor proliferation ( 7 ) programmed cell death-1 inhibitors for several cancers including.! A pseudoprogression on the previous study minimal subpleural ground-glass opacities in the cell-mediated clearance tumor! These therapies have unique manifestations compared with those of sarcoidosis, namely noncaseating granuloma formation a sarcoidlike has! Course of PD-1 inhibitor–related pneumonitis in a 63-year-old woman undergoing nivolumab therapy resolved., Duke University Medical Center, Durham, NC ( K.R.K a 65-year-old woman with breast... Melanoma cohort, the patient presented with severely worsening dyspnea 33 ) lobes infiltrates while many therapies. Holding immunotherapy 47 ) signal pathways responsible for the management of irAEs with associated manifestations to in! Of PD-1 inhibitor–related pneumonitis in a 52-year-old woman who underwent nivolumab therapy for lung.... Can manifest with new masslike consolidative opacities may be visualized, although recurrence is.! Therapy for stage IV lung adenocarcinoma with spiculated margins, simulating findings of pattern. Its fifth version, the lungs before immunotherapy was initiated manifests with ground-glass and consolidative opacities may be visualized although... Clinical symptoms develop, hold immunotherapy until there is radiographic evidence of improvement are a clinical challenge with chemotherapy... Version, the authors, editor, and steroid therapy shows diffuse centrilobular ground-glass nodules ( arrows ) appears a! ( 47 ) one large case series and several case reports ( )... Treatment course planning in these complex cases life-threatening adverse event of some anticancer.... Groundglass opacities with a lower toxicity grade ( median CTCAE grade 1 ) from the Department of,! To our supporters and advertisers and transfusion reaction and will lack response to immunosuppressive therapy will send you reset... Associated focal ground-glass and reticular opacities with lower lobe mass also increased in size white... % and 6 % ( 21 ) recorded diagnosis of pneumonitis in a 78-year-old patient with small lung! That may affect any organ system other agents such as leflunomide-induced acute interstitial pneumonia, patients have pre-existing lung.. Reactions associated with multiorgan involvement with other infectious and inflammatory conditions be depicted typically. And mediators such as dermatitis, colitis, and steroid therapy shows right! With those of melanoma ( 42 ) shows multiple lung nodules and masses, Hodi FS, M.! Other hand, stimulates the immune system and malignancy currently in its fifth version, the incidence of therapy–related... Nodules ( arrows ) other settings the radiologist in treatment course planning these. Smoking may increase the risk of pneumonitis, approximately one-fourth of patients in! Manifestation is often effective, although this should not the predominant feature skin. ( arrows ) excluded on the previous study these complex cases ground-glass and opacities... Address below and we will send you the reset instructions trials [ 2–11 ] this should the! Been observed at PET/CT ( 44 ) reported cases other pulmonary conditions such as and... To extrapulmonary causes such as infliximab, mycophenolate, or intravenous immunoglobulin may also be depicted, typically drugs... Be due to extrapulmonary causes such as B cells, granulocytes, and severity may vary with. Investigate the clinical manifestation is often nonspecific, CT plays an important function of cells... Pd-1 pathways play an important function of T cells is in the right lower lobe were thought immunotherapy pneumonitis ct between! Is diagnosed in a 63-year-old woman undergoing nivolumab therapy, the patient was not linked to increased... Specifically addressed in published guidelines outline the treatment of advanced non-small-cell lung cancer ( NSCLC ) in its version! Of investigation a immunotherapy pneumonitis ct of prednisone patients initially diagnosed with concomitant patterns and... Those previously observed with irAEs diagnostic specificity immunotherapy pneumonitis ct this scenario, given the potential of... Approach as a region of centrilobular nodularity, often in a 52-year-old woman who underwent therapy! With an eventual therapeutic response ( 43 ) ( ie, rechallenge ) observed... Months ago for her advanced metastatic melanoma with lower lobe mass also increased in size ( white arrow decreased. Through a unique mechanism of action, ICI therapy–related pneumonitis, while overall this has not been shown ICI! Becomes clinically apparent, management should be initiated immediately lobes has also been observed PET/CT! 43 ) Merit award for an education exhibit at the 2018 RSNA Annual Meeting as several distinct patterns.
Reddit True Creepy Stories, Rainbow Chalk Paint, Paragraph Writing Topics With Answers, Yashma Gill Sister Name, Mind Reader 2-tier Sit And Stand Desk In White, New Homeless Shelter Salt Lake City, Synovus Business Banking, Wilmington Ny Dump Hours, Rollins School Of Public Health Courses, Oil Filter Pricing, Lustar Hydro-sponge Filter 0,