Endoscopic evaluation of immunotherapy-induced gastrointestinal toxicity

Abstract

Immunotherapy is any treatment aimed at boosting or enhancing the immune system. It includes a wide range of options, from vaccines to treatment for conditions such as allergy and cancer. In the case of cancer, unlike other available treatments, immunotherapy is not aimed at destroying the tumor cells but at stimulating the patient's immune system so that it attacks the tumor. In cancer, immunotherapy provides a series of advantages. Nevertheless, immunotherapy administered for treatment of cancer is associated with immune-mediated enterocolitis. Colitis mediated by monoclonal anti-cytotoxic T lymphocyte-associated antigen 4 and to programmed cell death protein 1 and its ligand PDL1 shares characteristics with chronic inflammatory bowel disease (IBD), and similar findings have been reported for both the endoscopy images and the segment involved. The most frequent lesions on endoscopy are ulcer and erythema, and the most frequently affected site is the sigmoid colon. A segmental pattern has been reported to be slightly more frequent than a continuous pattern. In addition, upper gastrointestinal lesions have been reported in up to half of patients, with the most frequent findings being gastritis and erosive duodenitis. As is the case in IBD, systemic corticosteroids and immunosuppressive treatment (anti-TNF agents) are the approaches used in patients with a more unfavorable progression. Immunotherapy must be suspended completely in some cases.

Keywords: Endoscopy; Enterocolitis; Immune-related adverse event; Immunotherapy; Ipilimumab; Nivolumab; Toxicity.

Figure 1

Mucosa at the rectosigmoid junction with mild erythematous spots and no erosions or ulcers.

Figure 2

Mucosa at the rectosigmoid junction with erythema and fibrin-covered superficial erosions.

Figure 3

Mucosa in the descending colon with extensive erythema and deep fibrin-covered ulcers.

Figure 4

Erosion on the mucosa of the gastric antrum with generalized erythema.

Figure 5

Petechiae on the mucosa of the gastric fold.