Kawata Kana, Inoue Dai, Komori Takahiro, Matsubara Takashi, Toshima Fumihito, Kozaka Kazuto, Yanagi Masahiro, Ikeda Hiroko, Kobayashi Satoshi
Kanazawa University Hospital, Kanazawa, Japan.
Abdom Radiol (NY). 2025 May 27. doi: 10.1007/s00261-025-04994-w.
The use of immune checkpoint inhibitors has increased in the field of oncology; however, various immune-related adverse events affecting multiple organs have been reported. Herein, we present a case of concurrent hepatitis, cholangitis, and pancreatitis as immune-related adverse events (irAE); a case of autoimmune disease due to oncologic immunotherapy. A man in his 80s who was undergoing pembrolizumab therapy for recurrent renal pelvic cancer presented to the emergency department with a loss of appetite. Laboratory tests revealed elevated levels of inflammatory markers and liver enzymes. Initial non-contrast computed tomography (CT) suggested cholecystitis and cholangitis, for which antibiotics were administered. However, because of poor improvement, contrast-enhanced dynamic CT and gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic acid-enhanced magnetic resonance imaging (MRI) were performed two weeks after visiting the emergency department to reassess the underlying cause. In these examinations, besides the bile dust wall thickening and edematous changes along Glisson's sheath suggesting the cholangitis, inflammatory enlargement in pancreatic tail was also revealed. Considering these imaging findings suggesting the cholangitis and pancreatitis during pembrolizumab therapy, irAE was suspected as the cause of symptoms. A liver biopsy subsequently performed strongly indicated hepatitis and cholangitis as irAE. Based on these findings, concurrent hepatitis, cholangitis, and pancreatitis as irAE by pembrolizumab were diagnosed. Imaging findings of irAE cholangitis are similar to those of primary sclerosing cholangitis and IgG4-related cholangitis. Particularly in cases like this one, where pancreatitis is also present. However, if a history of immune checkpoint inhibitor use is known, it is possible to include irAE in the differential diagnosis, as observed in this case. Therefore, by keeping the use of immune checkpoint inhibitors in mind during imaging interpretation, imaging examinations could be a clue to suggest the possibility of irAE. Recognizing the imaging findings associated with irAEs and the existence of cases where irAE cholangitis and irAE pancreatitis coexist, it can aid earlier diagnosis of irAEs.
免疫检查点抑制剂在肿瘤学领域的应用有所增加；然而，已报告了多种影响多个器官的免疫相关不良事件。在此，我们报告一例同时发生肝炎、胆管炎和胰腺炎的免疫相关不良事件（irAE）病例；这是一例因肿瘤免疫治疗导致的自身免疫性疾病。一名80多岁的男性因复发性肾盂癌接受派姆单抗治疗，因食欲不振到急诊科就诊。实验室检查显示炎症标志物和肝酶水平升高。最初的非增强计算机断层扫描（CT）提示胆囊炎和胆管炎，为此给予了抗生素治疗。然而，由于病情改善不佳，在就诊急诊科两周后进行了增强动态CT和钆塞酸二钠增强磁共振成像（MRI）以重新评估潜在病因。在这些检查中，除了提示胆管炎的胆管壁增厚和沿肝门管区的水肿改变外，还发现胰尾有炎症性肿大。考虑到这些影像学表现提示派姆单抗治疗期间发生胆管炎和胰腺炎，怀疑症状的原因是irAE。随后进行的肝活检强烈提示肝炎和胆管炎为irAE。基于这些发现，诊断为派姆单抗导致的同时发生的肝炎、胆管炎和胰腺炎的irAE。irAE胆管炎的影像学表现与原发性硬化性胆管炎和IgG4相关性胆管炎相似。特别是在像本例这样同时存在胰腺炎的情况下。然而，如果已知有免疫检查点抑制剂使用史，就有可能在鉴别诊断中考虑irAE，如本例所见。因此，在影像学解读过程中牢记免疫检查点抑制剂的使用情况，影像学检查可能成为提示irAE可能性的线索。认识到与irAE相关的影像学表现以及irAE胆管炎和irAE胰腺炎共存的病例存在，有助于更早诊断irAE。
