Skill Checkup: A 48-Year-Old Triple-Negative Breast Cancer Patient Falls Ill During Immune Checkpoint Inhibitor Therapy

Kelly E. McCann, MD, PhD

Disclosures

May 24, 2022

Current recommendations advise that pulmonary consultation for bronchoscopy with bronchoalveolar lavage should be performed for suspicion of ICI-related pneumonitis to narrow the differential and to rule out atypical and opportunistic infections, particularly as treatment of pneumonitis typically involves immunosuppression with glucocorticoids. The differential diagnosis includes cryptogenic organizing pneumonia, nonspecific interstitial pneumonitis, hypersensitivity pneumonitis, or usual interstitial pneumonitis/PF. Both clinical and radiographic findings of ICI-related pneumonitis may also appear very similar to those of pneumonia, lymphangitic spread of disease, cancer progression, and diffuse alveolar hemorrhage.

On imaging, ICI-related pneumonitis can be identified by the presence of new or progressive pulmonary infiltrates (usually bilateral but can be asymmetric) and centrilobular ground-glass opacities. CT imaging is considered the first-line approach in this context and more reliable than chest radiographs in detecting such changes. However, bronchoscopy allows for a more nuanced analysis, as many conditions in the differential (as noted above) present similarly on CT.

Lung biopsies are typically not indicated for management of patients with pulmonary IRAEs but can be considered for the identification of atypical lesions, unexplained lymphadenopathy, or if there is suspicion of acute infection or cancer progression. Critically, pulmonary symptoms can point to disease progression and lung metastases, and new respiratory symptoms should be assessed.

In monitoring pneumonitis, baseline and ongoing oxygen saturation (at rest and on ambulation) should be routinely checked. Chest CT, pulmonary function tests, and a 6-min walk test should also be performed. As previously described, the management of IRAEs is largely multidisciplinary, and pulmonology consult is indicated with suspected pneumonitis. Fever and productive cough may also prompt an infectious disease consultation.

Upon further workup, the patient's pneumonitis is deemed to be grade 2 (symptomatic, limiting activities of daily living, medical intervention indicated). There is no suspicion of acute infection or cancer progression at this time.

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