Refractory bullous pemphigoid during treatment with pembrolizumab in the first-line treatment of advanced non-small cell lung cancer

Renata Olech, Monika Rychlik-Grabowska, Sławomir Mańdziuk
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Abstract

Dermatological toxicity is one of the most common immune-related adverse events (irAEs) of treatment with immune checkpoint inhibitors (ICIs). Bullous pemphigoid (BP) is a rare and serious complication of these drugs that can be difficult to establish, as its initial symptoms may be indistinguishable from mild skin lesions. This paper presents the case of a 68-year-old patient who developed BP after receiving one of the ICI therapies, pembrolizumab, for advanced non-small cell lung cancer (NSCLC). After approximately 7 months of therapy, a grade 3 skin toxicity in the Common Terminology Criteria for Adverse Events (CTCAE) occurred in the form of rash and pruritus. Pembrolizumab was then held and prednisone and antihistamines were introduced. When dermal toxicity improved to grade 1, pembrolizumab was resumed and prednisone was kept at a dose of 10 mg. Immunotherapy was discontinued 3 months later, after the recurrence of grade 3 skin toxicity symptoms. When the patient developed blisters filled with clear fluid, dermatologists suspected pembrolizumab-induced bullous pemphigoid. Bullous pemphigoid was subsequently confirmed using a direct immunofluorescence test and histopathological examination. The patient’s skin condition improved after the use of steroid therapy and methotrexate, and the cancer process stabilized for over one year. Cancer progression and deterioration of the patient’s general condition were observed approximately 4 months after the termination of pembrolizumab therapy. The paper also discusses the key aspects of ICIs-induced BP, especially pembrolizumabinduced BP in the first-line treatment of metastatic NSCLC. Early diagnosis of skin lesions and the initiation of appropriate treatment may lead to better outcomes for patients and prevent disruptions in immunotherapy. Forum
帕姆单抗一线治疗晚期非小细胞肺癌期间的难治性大疱性类风湿关节炎
皮肤毒性是免疫检查点抑制剂(ICIs)治疗中最常见的免疫相关不良事件(irAEs)之一。大疱性类天疱疮(BP)是这类药物的一种罕见而严重的并发症,由于其初期症状可能与轻微皮损无异,因此很难确定。本文介绍了一名 68 岁患者的病例,该患者在接受 ICI 疗法之一--pembrolizumab--治疗晚期非小细胞肺癌(NSCLC)后出现了丘疹性荨麻疹。治疗约 7 个月后,出现了皮疹和瘙痒等不良事件通用术语标准(CTCAE)中的 3 级皮肤毒性。随后暂停使用 Pembrolizumab,并开始使用泼尼松和抗组胺药。当皮肤毒性改善到1级时,重新开始使用Pembrolizumab,并将泼尼松的剂量保持在10毫克。3个月后,3级皮肤毒性症状再次出现,免疫疗法中断。当患者出现充满透明液体的水泡时,皮肤科医生怀疑是彭博利珠单抗诱发的大疱性类丘疹。随后,通过直接免疫荧光试验和组织病理学检查证实了大疱性类天疱疮。使用类固醇治疗和甲氨蝶呤后,患者的皮肤状况有所改善,癌症进程稳定了一年多。在终止使用 pembrolizumab 治疗约 4 个月后,观察到癌症进展和患者全身状况恶化。本文还讨论了 ICIs 诱导的 BP,尤其是 Pembrolizumab 诱导的 BP 在转移性 NSCLC 一线治疗中的关键环节。皮肤病变的早期诊断和适当治疗的启动可为患者带来更好的治疗效果,并防止免疫疗法的中断。论坛
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