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Gabriella Oliveira Mendes



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    P2.04 - Immuno-oncology (ID 167)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Immuno-oncology
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/09/2019, 10:15 - 18:15, Exhibit Hall
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      P2.04-71 - Bullous Pemphigoid: A Rare Immunomediated Event Secondary to Immunotherapy in a Patient with Metastatic Lung Cancer (Now Available) (ID 2860)

      10:15 - 18:15  |  Author(s): Gabriella Oliveira Mendes

      • Abstract
      • Slides

      Background

      Checkpoint Inhibitors (CIs) are already part of the armamentarium in lung cancer treatment, either alone or in combination with chemotherapy. By stimulating the immune system, activation of autoreactive T lymphocytes can lead to development of immune-mediated adverse events. Dermatological toxicities are the most common of these events and may affect up to 50% of patients. The most common are pruritus, rash, dermatitis and bullous dermatitis.

      We present the case of a patient with metastatic lung adenosquamous carcinoma, using pembrolizumab as a second line treatment who developed pemphigus.

      Method

      Case Report

      Result

      A 64-year- old female was diagnosed with oligometastatic lung adenosquamous carcinoma (bones). There were no EGFR, BRAF mutations or ALK, ROS translocations. PDL1 expression was 20% (22c3 antibody). Patient received first line treatment with six cycles of carboplatin and paclitaxel, with partial response, but limiting toxicity. Radiotherapy was performed as consolidation in lung and active bone lesion in thoracic spine. There was an early progression in primary lesion, and pembrolizumab was initiated as second line.After five cycles, there was disease progression, and treatment was withhelded. Six weeks later, the patient presented with bullous, hyperemic and painful lesions on both feet sole, buttocks, upper limbs, and oral mucosa. Biopsy was performed and revealed superficial and deep perivascular dermatitis with subepidermal blister and numerous eosinophils. The direct immunofluorescence test revealed presence of IgG and C3 deposits, in a linear pattern, in the membrane region. These findings lead to the diagnose of bullous pemphigoid. The lesions regressed completely after topical corticosteroid therapy used for one month. Next Generation Sequence (Foundation One) was performed, a mutation was identified in MET (exon 14) and she is currently receiving crizotinib with partial response and good tolerance. There are no new immunomediated late events.

      Conclusion

      Pembrolizumab is a monoclonal antibody (IgG4) which selectively inhibits PD-1 activity in the T cell, activating the immune system but also triggering immune mediated events (IrAE). Cutaneous toxicity are the most common IrAE. The occurrence of bullous pemphigus is extremely rare with only one report in the literature. It may have an early or late onset after treatment iniciation. It is usually preceded by pruritus and nonspecific macular lesions that appear in the trunk and limbs. Histology demonstrates a subepidermal blister with mixed inflammatory infiltrate with eosinophils and immunofluorescence reveals linear deposition of IgG and C3 in the membrane. Management should ideally involve a dermatologist and require the use of systemic or topical corticosteroids, depending on the disease burden. In severe cases, immunotherapy should be discontinued. In our case, dermatologic toxicity had a late but symptomatic onset and a good response was obtained with the use of topical corticosteroids.

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