Diagnosis and management of pulmonary toxicity associated with cancer immunotherapy

Abstract

Pulmonary toxicity of cancer immunotherapies has emerged as an important clinical event that requires prompt identification and management. Although often referred to as pneumonitis, pulmonary toxicity associated with immunotherapy covers a broad and overlapping spectrum of pulmonary manifestations, and, once suspected, the range of differential diagnoses of infectious and neoplastic processes might make the diagnostic process challenging for physicians. Optimal care can require multidisciplinary effort by pulmonologists, medical oncologists, and radiologists, and awareness of the possibility of treatment-induced pulmonary toxicity by emergency department and primary care physicians. This Viewpoint gives an overview of the diagnosis and management of pulmonary toxicity arising from cancer immunotherapy, including widely used treatments, such as immune checkpoint inhibitors, and emerging therapies, such as chimeric antigen receptor T cells.

Figure 1:. Clinical manifestations of immune checkpoint related pulmonary toxicity

Symptoms might include dyspnoea, chest discomfort, cough, hypoxia, or, less commonly, fever. Differential diagnosis includes disease -related complaints or other treatment-related complications such as infection or anaemia.

Figure 2:. Selected case examples of checkpoint inhibitor associated pneumonitis

toxicity Case listings include: demographics, cancer type, immunotherapy type, pneumonitis onset, and radiographic appearance. (A) 87-year-old man, non-small-cell lung cancer (NSCLC), anti-programmed cell death ligand 1 (PDL1), 9 weeks, reticulonodular opacities, and septal thickening. (B) 60-year-old man, renal cell carcinoma, antiprogrammed cell death protein 1 (PD1), 5 months, nodular opacities. (C) 77-year-old man, melanoma, combination anti-PD1 and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor, 6 weeks, patchy ground glass and nodular consolidation, cryptogenic organising pneumonia. (D) 71-year-old man, NSCLC, anti-PD1, 2 weeks, mosaic attenuation of ground glass opacities. (E) 70-year-old man, NSCLC, anti-PD1, 1 month, consolidation. (F) 78-year-old man, NSCLC, anti-PDL1, 4 months, consolidations and ground glass densities in the bases.