Immunotherapy with Autoimmune Complication in Renal Cancer

Newer modalities like immunotherapy with checkpoint inhibitors are widely being used in oncology. Complete remission with immunotherapy comes along with immune related adverse effects which warrant prompt diagnosis and treatment. Below is a case metastatic RCC treated with pembrolizumab, humanized monoclonal antibody to programmed cell death receptor with autoimmune complications during therapy and subsequent complete remission after re-challenge.

72 year old gentleman with background history of diabetes mellitus, hypertension presented with complaints of hematuria and neck pain. Upon evaluation, found to have RCC with metastasis to lungs and left occipital condyle. Patient underwent excision nd prosthesis for unstable atlanto-occipital joint, left nephrectomy for malignant focus in left kidney. He was then started on immunotherapy, inj. pembrolizumab +tab. axitinib.

After three cycles of immunotherapy, patient presented with easy fatigability, weakness and drowsiness. Baseline TSH and liver functions were normal. Investigations revealed high TSH and transaminitis. Autoimmune hepatitis was treated with steroids and oral levothyroxine was started for autoimmune thyroiditis. Patient improved with treatment and immunotherapy was re-challenged. After 12 cycles of pembrolizumab, review PET-CT scan showed no lung lesions and complete metabolic response.

Immunotherapy has very good results in advance malignancies. It has unique side effects of auto immune phenomenon. Therapy can be re-challenged if its complications of autoimmune adverse events are diagnosed and treated promptly. References Nagra NK, Siddique A, Singhvi G, et al. S2684 pembrolizumab induced hepatitis: a severe complication effectively treated with steroids. Am J Gastroenterol 2020;115:S1405-S1406. Choueiri TK, Tomczak P, Park SH, et al. Adjuvant pembrolizumab after nephrectomy in renal-cell carcinoma. N Engl J Med 2021;385:683-694.