Pleuritis and peripheral edema due to Immunotherapy
- 73 year old patient
- Melanoma of unknown primary
- stage IV M1d (1), BRAF wildtype, NRAS Mutation, c-Kit wildtype
- 08/2016: iliac lymph node metastasis (3,5 x 2,5 x 1,5 cm)
- 10/2017: hemorrhagic cerebral metastasis
- 11/2019: lymph node metastasis of the left tigh
- 03/2020: cutaneous metastases
- 10/2016 – 11/2016: radiotherapy
- 01/2017: lymph node dissection inguinal left
- 10/2017: resection of cerebral melanoma metastasis
- 11/2017: stereotactic radiotherapy in area of resected metastasis
- 11/2017 – 11/2018: pembrolizumab
- 11/2019: resection of lymph node metastasis
- 03/2020 – 05/2020: intratumoral oncolytic viral therapy
One year after initiation of the immunotherapy with Pembrolizumab the patient presented with massive edema of both lower legs, thighs and scrotum as well as dyspnea due to pleural effusion.
A cardiovascular as well as nephrological genesis of the edema and pleural effusions could be excluded (normal left ventricular function, serumelectrophoresis without pathological findings, exclusion of proteinuria).
Pleura puncture was conducted. Pleural fluid did not show any malignant cell but lots of lymphocytes, expecting it to be the result of an immune-related pleuritis. Prednisone with 30 mg per day was initiated.
Immunotherapy was interrupted. The prednisone in combination with diuretic therapy initially led to a reduction of the edemas. A few weaks after tapering off the steroids, recurrent pleural effusion was observed. Therefore Pembrolizumab could not be rechallenged again. Unfortunately the patient died due to deterioration of his general condition.
Only few publications report the occurence of immune-related serositis, mostly affecting patients with metastatic lung cancer and pericardial effusions. Most patients present with dyspnea, but also asymtomatic pericardial effusion was described, expecting the incidence to be higher than initially thought (Anastasia et al., Journal for ImmunoTherapy of Cancer, 2019). Other authors describe rapidly accumulating effusions under Nivolumab especially in patients with malignant involvement of visceral spaces. Sometimes it might be hard to differentiate between tumour progression and immune-related adverse event. In such cases the detection of lymphocytes in the pleural or pericardial fluid might be helpful, pointing out a positive effect of steroids (Kolla and Patel, Journal for ImmunoTherapy of Cancer, 2016).
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