Immune check-point blockade agents have become the standard of care for an increasing number of indications over the last few years. These drugs are associated with immune-related adverse events (irAEs) whose incidence varies depending on the immune check-points which are being inhibited. Gastrointestinal toxicity from cancer immunotherapy appears to be more frequent for anti-CTLA-4 than for anti-PD1 or anti-PD-L1, the target of Nivolumab.1 Although irAEs including the lower gastrointestinal tract are well known in anti-PD1 treatment; the gastritis or the esophagitis remain sporadic effects.2 In our center, two cases of acute pangastritis have been reported in one year.
We carried out a retrospective, descriptive study. We reviewed the clinical history of those patients who had received Nivolumab for any indication from January 2017 to December 2021 in our tertiary center. We selected those with upper gastrointestinal symptoms and for whom an upper gastrointestinal diagnosis had been reached by an esophagogastroduodenoscopy (OGD).
Of the overall 100 patients treated with Nivolumab in this period, two cases of gastritis were detected, which supposes an incidence rate of 2% (IC 95% −0.007, 0.047). The first patient was a 47 years-aged man with a personal history of malignant non-metastatic melanoma (pT3bN2M0) radically removed. He underwent adjuvant therapy with Nivolumab for recurrence prevention and was admitted to our ward with epigastric pain and hyporexia. The second patient was a 64 year-old woman diagnosed with a metastatic choroidal melanoma previously treated with local surgery who reported epigastric pain in the last month. In both cases the symptoms started just after receiving the 9th dose of treatment which corresponds to 4.5 months follow-up period. Their basal characteristics are summarized in Table 1. For the two cases, preferential ODG were performed, showing an intense inflammation throughout the stomach. Macroscopically, the mucosa was erythematous, edematous, with friability and extense ulcerations covered with fibrine. In both cases the biopsies taken revealed inflammatory neutrophilic infiltration into the epithelium, as well as cellular apoptosis and crypt microabscesses, all of which was related to Nivolumab drug-induced pangastritis. No form of Helicobacter Pylori was identified in any case. CMV determinations by IHQ and biopsies were also negative. Medical treatment with double-dose of proton-pump inhibitor and definitive cessation of Nivolumab was established, becoming the first patient rapidly asymptomatic. However our second patient didn’t show any improvement after several weeks of oral treatment so she remained hospitalized with IV corticosteroids, observing a complete remission of his symptoms.
Basal characteristics of the two patients receiving nivolumab who developed an acute gastritis.
| Patient 1 | Patient 2 | |
|---|---|---|
| Age | 47 | 64 |
| Sex | Male | Female |
| Tumor | Skin melanoma | Choroidal melanoma |
| Stage of disease | Stage III | Stage IV |
| Cycles of nivolumab | 9 | 9 |
| Previous immune-related adverse events | No | No |
| History of autoimmune disease | No | No |
| Helicobacter pylori | No | No |
| Previous treatment with immunotherapy | No | No |
Nivolumab is a PD-L1 inhibitor extendedly used in metastatic, locally advanced or recurrent malignant diseases such as melanoma, non-small-cell lung cancer, renal cell or urothelial carcinoma, Hodgkin's disease, and squamous cell carcinoma of the head and neck.1 It leads to the activation of the cytotoxic immune response which is normally carried out by LT-CD8 against malignant cells.1 The immune-mediated gastritis is a rare adverse event, which can appear several months after the beginning of the treatment but also after its discontinuation. The differential diagnosis must be reached by excluding infectious gastritis, vasculitis, Crohn's disease or Behçet syndrome. The pathologist must always know the involvement of this treatment in order to achieve a reliable diagnosis.3 The role of Helicobater Pylori must be highlighted in this case. Since it is capable of simulating or even worsening the immune mediated gastritis, not only its identification but also its eradication becomes essential.4 The treatment is based on the immediate cessation of the immunotherapy, the gastric acid suppression and high doses of corticosteroids in the most severe cases. Benefits of immunosuppressive treatment using infliximab have been shown in refractory cases.5
Conflict of interestsThe authors declare no conflict of interests.
