A Therapy-Terminating Event: Programmed Death-1 Inhibitor-Induced Mucositis

Area of Science:

• Oncology
• Immunology
• Dermatology

Background:

• Oral mucositis is a painful inflammatory condition and a common immune-related adverse event (IRAE) associated with cancer immunotherapy.
• Programmed death-1 (PD-1) inhibitors are increasingly used in cancer treatment, highlighting the need to understand their associated toxicities.
• Severe oral mucositis can lead to significant morbidity, including infection, cachexia, and cessation of life-saving cancer therapy.

Observation:

• This case series details three elderly patients (73-81 years) who developed Grade III oral mucositis during PD-1 inhibitor therapy for cancer.
• Patients presented with painful, swollen, and ulcerated oral mucosa, leading to dysphagia and odynophagia, despite conservative management with local anesthetics and antimicrobial mouthwashes.
• Two patients developed mucositis after the seventh cycle, and one after the fourth cycle, with no prior history of oral pathology.

Findings:

• Systemic glucocorticoid therapy, initiated after conservative measures failed, resulted in the resolution of oral mucositis in all three patients.
• The successful treatment of mucositis allowed patients to resume their PD-1 inhibitor immunotherapy without interruption.
• This suggests a critical role for systemic steroids in managing severe cases of immunotherapy-induced oral mucositis.

Implications:

• Immunotherapy-induced oral mucositis is a debilitating IRAE requiring prompt and effective management.
• Systemic glucocorticoids, particularly with a prolonged taper, represent a crucial treatment modality for severe oral mucositis, addressing the underlying inflammation.
• Early recognition and intervention with systemic steroids are vital for managing oral mucositis, improving patient quality of life, and preventing delays in cancer treatment.