Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
J Oncol Pharm Pract. 2021 Sep;27(6):1548-1552. doi: 10.1177/1078155220981155. Epub 2021 Jan 12.
Nivolumab, a programmed death-1(PD-1) inhibitor antibody, have demonstrated anti-tumor activity for multiple malignancies. Such immune checkpoint inhibitors induce novel and distinctive adverse effects, which are collectively named immune-related adverse events. Immune-related adverse events can theoretically occur at any part of the body, including the haemopoietic system. Most immune-related adverse events developed within 10 weeks of receiving immunotherapy. Thus far, there is no report of immune thrombocytopenia as an immune-related adverse event developed after discontinuation of immunotherapy.
We describe a 62-year-old male with metastatic non-small cell lung cancer developed immune thrombocytopenia nearly two months after discontinuation of nivolumab. When thrombocytopenia was detected, the patient was undergoing radiotherapy of supraclavicular lymph nodes. After complex diagnosis-by-exclusion process, nivolumab-induced immune thrombocytopenia was diagnosed.
Intravenous immunoglobulins 20 g daily for 5 days, intravenous methylprednisolone 40 mg daily for 14 days followed by oral prednisone, intermittent platelet transfusion and oral thrombopoietin receptor (eltrombopag 25 mg daily) were administered. After 30 days, his platelet count had achieved a level of adequate hemostasis and continued to improvement during the tapering period.
Most immune-related developed 6 months of immunotherapy. Clinicians need to be aware of a clinical diagnostic complex, developing months to years after discontinuation of immunotherapy, which recently is termed delayed immune-related events. This case is the first report of immune checkpoint inhibitors-induced thrombocytopenia that developed nearly 2 months after discontinuation of treatment with nivolumab for metastatic NSCLC. In future clinical practice, patients who have received immune checkpoint inhibitors develop new or unexplained symptom, irrespective of interval post-immunotherapy, immune-related adverse events should be considered.
Nivolumab 是一种程序性死亡受体-1（PD-1）抑制剂抗体，已证明对多种恶性肿瘤具有抗肿瘤活性。这些免疫检查点抑制剂会引起新的、独特的不良反应，统称为免疫相关不良反应。免疫相关不良反应理论上可发生在身体的任何部位，包括造血系统。大多数免疫相关不良反应发生在接受免疫治疗后 10 周内。迄今为止，尚无免疫治疗停止后发生免疫性血小板减少症作为免疫相关不良反应的报告。
我们描述了一名 62 岁男性患有转移性非小细胞肺癌，在停止使用 nivolumab 近两个月后发生免疫性血小板减少症。当发现血小板减少症时，患者正在接受锁骨上淋巴结放疗。经过复杂的排除诊断过程，诊断为 nivolumab 引起的免疫性血小板减少症。
给予患者每日 20g 静脉注射免疫球蛋白 5 天，每日 40mg 静脉注射甲基强的松龙 14 天，随后口服泼尼松，间歇性血小板输注和口服血小板生成素受体（艾曲波帕 25mg 每日）。30 天后，他的血小板计数达到了足够止血的水平，并在减量期间继续改善。
大多数免疫相关不良反应发生在免疫治疗 6 个月后。临床医生需要意识到一种临床诊断复杂的情况，这种情况在免疫治疗停止后数月至数年内发生，最近被称为延迟免疫相关事件。这是首例 nivolumab 治疗转移性非小细胞肺癌停止治疗近 2 个月后发生免疫检查点抑制剂诱导的血小板减少症的报告。在未来的临床实践中，无论免疫治疗后间隔如何，接受过免疫检查点抑制剂治疗的患者出现新的或无法解释的症状，都应考虑免疫相关不良反应。
