Mr. Hu is a 64-year-old patient with advanced lung adenocarcinoma. He was diagnosed with lung cancer two years ago. He has metastasized to the ribs and sternum. He has no chance of surgery. Any susceptible gene mutation. Therefore, chemotherapy combined with bevacizumab was started, and the treatment was maintained for one year, and the condition was controlled and stabilized for a time. However, in 2021, the lung lesions will increase and the disease will progress, and they will be treated with domestic immunotherapy drugs combined with chemotherapy for 4 cycles to achieve partial remission. One day at the outpatient clinic, Mr. Hu came to see a doctor with chest tightness, asthma, and facial edema. A chest CT scan revealed typical interstitial pneumonia in both lungs, and pleural effusion and pericardial effusion. He was admitted to the hospital for hormone therapy urgently, and the symptoms were significantly relieved after a week. , The pleural effusion disappeared after a month of review. The immunotherapy drug was discontinued, and the second-line chemotherapy combined with bevacizumab was replaced, but it progressed again after half a year. The patient is very anxious now, what should I do next? Can immunotherapy be restarted?
PD-1/PD-L1 inhibitors kill tumors by activating the autoimmune system, but when immune cells are overactivated and immune abnormality occurs, they will in turn attack their own tissues. If it affects the lungs, immune-related pneumonia occurs. Mr. Hu developed typical immune pneumonia after using PD1 inhibitor 4 times.
Immune pneumonitis is a relatively common immune-related adverse reaction, with a median time of 2.8 months. Clinical statistics show that among all patients using immunotherapy drugs, the overall incidence of immune-related pneumonia can reach 20% to 40%, most of which are mild, with grades 1-2 accounting for 72%, and the incidence of severe pneumonia. less than 5%. Immune pneumonia accounted for more than one-third of immunotherapy-related deaths. It can be seen that immune pneumonia is an immune-related adverse reaction that requires special attention in clinical practice.
Can a patient with immune pneumonia restart immunotherapy after recovery?
Immune-related pneumonia clinical symptoms mainly include dyspnea (53%), decreased activity tolerance, cough (35%), fever (12%) or chest pain (7%), but approximately One-third of patients were asymptomatic and only had imaging abnormalities. According to clinical manifestations, it can be divided into 4 grades. Grade 1: No clinical symptoms, only imaging findings. Grade 2: There are imaging findings, which slightly interfere with daily activities. Level 3/4: Severely affects the ability to take care of yourself in daily life.
Generally speaking, patients with suspicious lesions on the lungs without any symptoms will be temporarily observed, continue the cycle of immunotherapy, and check infectious indicators, and empirical antibiotic treatment will be given first, 3 – 4-week review CT evaluation. Once symptoms are present and immunological pneumonia is diagnosed, immunotherapy should generally be stopped, and empiric antibiotics combined with hormone therapy should be used. If it develops to grade 3-4, empiric antibiotic therapy combined with high-dose steroid pulse for 2-3 days as soon as possible, if there is no improvement, combined with gamma immunoglobulin or other immunosuppressive therapy.
If the previous immunotherapy has achieved partial remission or stable disease, but the treatment cycle is not enough, it may be considered to challenge the immunotherapy. The selected population is generally those with grade 1-2 immune pneumonia who are hormone-sensitive and recover well, and those who have previously experienced grade 3-4 immune pneumonia, and need to be cautious when restarting immunotherapy. For those who did not respond well to immunotherapy in the early stage, there is no need to try to restart immunotherapy.