Pembrolizumab‐induced mucositis in a patient with recurrent hypopharynx squamous cell cancer

Abstract

Pembrolizumab, an anti‐PD‐1 checkpoint inhibitor, is used in patients with recurrent or metastatic squamous cell carcinoma of the head and neck who have received prior therapy with a platinum‐based regimen. As a monotherapy, it is generally well tolerated, but a small percentage of patients may develop immune‐mediated inflammatory reactions. We report a case of mucositis and laryngeal edema in a patient on pembrolizumab and review the literature. Laryngoscope, 130:E140–E143, 2020

Management of pembrolizumab-induced steroid refractory mucositis with infliximab: A case report

“…In fact, workup usually involves imaging studies, direct laryngoscopy and biopsy as well as bacterial and fungal culture even in the absence of visible thrush or leukocytosis. Direct visualization and biopsy typically show ulcerated mucositis with granulation tissue and absence of infectious features and malignancy[ 14 , 15 ].…”

“…Steroids remains the mainstream treatment for pembrolizumab-related adverse effects[ 21 ]. To date, only 2 cases of severe mucositis have been reported[ 14 , 15 ]. The first case of pembrolizumab-induced grade 4 immune mucositis and esophagitis was reported in 2018, and the adverse event resolved with discontinuation of pembrolizumab and initiation of intravenous methylprednisolone and subsequent oral prednisone tapering, although one recurrence of mucositis occurred during tapering period[ 14 ].…”

“…The first case of pembrolizumab-induced grade 4 immune mucositis and esophagitis was reported in 2018, and the adverse event resolved with discontinuation of pembrolizumab and initiation of intravenous methylprednisolone and subsequent oral prednisone tapering, although one recurrence of mucositis occurred during tapering period[ 14 ]. In a recent case report, the patient developed pembrolizumab-induced grade 4 mucositis after 1 year of treatment with 18 cycles of therapy with symptoms rapidly progressing, and the patient also developed recurrence of mucositis during the prednisone tapering period; therefore, prednisone regimen was adjusted to a prolonged and slow prednisone taper with the patient slowly achieving complete recovery from immunotherapy-mediated mucositis[ 15 ].…”

“…Although being concluded to be better tolerated than chemotherapy, multiple side effects of PD-1/PD-L1 inhibitors have been studied in a systematic review and meta-analysis including all-grade rash, colitis, hypothyroidism, transaminitis, and pneumonitis, with grade 3-4 mucositis remaining as a rare adverse effect of the immune checkpoint inhibitor[ 12 , 13 ]. To date, only 2 cases of pembrolizumab-induced severe mucositis have been reported, with patients achieved adequate recovery after steroid treatment[ 14 , 15 ]. Here, we report a first case of pembrolizumab-induced severe mucositis refractory to steroid therapy, but responded well to addition of infliximab to the steroid tapering course.…”

Clinical Characteristics and Outcomes of Oral Mucositis Associated With Immune Checkpoint Inhibitors in Patients With Cancer

“…[15][16][17] Furthermore, investigators have described adverse events in the oral cavity, including xerostomia, dysgeusia, lichenoid reactions, mucositis, and stomatitis. [18][19][20][21][22][23][24][25][26][27][28] The clinical presentation of ICI-mediated mucositis (IMM) can range from mild to severe, with onset ranging from several weeks to months after treatment initiation. [18][19][20][21][22][23] The literature contains several reports of severe mucositis induced by pembrolizumab, an anti-PD-1 agent, [24][25][26][27] with symptom onset occurring up to 1 year after initiation and mucositis lasting several months after discontinuation.…”