Pericardial effusion with pembrolizumab

Abstract

Introduction The treatment of non-small cell lung cancer (NSCLC) has profoundly changed on account of the arrival of new therapies, like immunotherapy. Within this group of drugs, those aimed at the programmed cell death-1 or programmed cell death ligand-1(PD1/PDL-1) are very relevant, for example, Pembrolizumab. Although its adverse reactions are generally mild and well tolerated, it has been associated with certain immune-related adverse events (IrAEs) than can be serious and affect any organ. Case report A 62-year-old woman diagnosed with stage IV NSCLC with a single bone metastasis and PD-L1 expression of 60% started treatment with cisplatin-pemetrexed-pembrolizumab, and maintenance with pembrolizumab. Management and outcome The patient attended the ER with pericardial effusion that was assumed to be a Pembrolizumab IrAE and was managed with corticosteroids. The patient fully recovered but immunotherapy was not reintroduced due to the severity of the AE. Discussion The cardiovascular system is among the least affected organs by immunotoxicity, with an incidence between 0.09–0.6%. However, some authors suspect the incidence is underestimated. Median time to onset is highly variable, ranging from 6 weeks since the first dose to 2 years after discontinuation of the treatment. There are not guidelines on the most effective management of the IrAEs, but according to the pharmaceutical reference, corticosteroids should be initiated followed by a progressive reduction. If no response is obtained, another immunosuppressive agent should be added. The determination to restart immunotherapy depends on the severity of the adverse reaction, the availability of other alternative treatments, and the cancer response.

Diagnosis and Management of Pembrolizumab-Associated Pericardial Effusion in a Non-small Cell Lung Cancer Patient

“…This technique is preferred when there is a concern for recurrent effusion in a long-term care setting, as it allows for the drainage of fluid into either the mediastinum or thoracic cavity without the need for multiple pericardiocentesis procedures [ 9 ]. It is this element of discussion and compromise that makes this case report unique from other cases of pembrolizumab-associated pericardial effusion wherein cancer treatment was halted without an attempt at a pericardiostomy middle ground [ 5 ].…”

“…For example, anti-PD-1 agents have been shown to be associated with complicating pneumonitis, especially in NSCLC patients with a history of pulmonary fibrosis [ 3 ]. Pembrolizumab has been shown to be a rare cause of pericardial effusion with the potential for acute pericardial tamponade, despite the fact that irAEs involving the cardiovascular system are generally rare with an estimated incidence of less than 0.6% [ 4 , 5 ]. Given the therapeutic potential for these agents in patients with advanced-stage cancer, an ideal treatment plan would theoretically involve their continued use with the clinical management of complicating irAEs [ 6 ].…”

Evaluation of Time-to-onset and Outcome of Cardiac Adverse Events Related to Pembrolizumab Using Post-Marketing Surveillance

“…Pembrolizumab has been used in combination with chemotherapy and has reportedly prolonged both overall and progression-free survival in clinical trials [2][3][4][5][6]. Despite bene cial effects in treating numerous types of tumours, pembrolizumab can cause a variety of adverse events (AEs) [2][3][4][5][6][7][8][9][10]. Among these, cardiac AEs resulting from pembrolizumab are rare but concerning AEs due to the high mortality rates [7][8][9][10].…”

“…Despite bene cial effects in treating numerous types of tumours, pembrolizumab can cause a variety of adverse events (AEs) [2][3][4][5][6][7][8][9][10]. Among these, cardiac AEs resulting from pembrolizumab are rare but concerning AEs due to the high mortality rates [7][8][9][10]. Studies using real-world databases have already evaluated AEs after pembrolizumab administration [11,12].…”