Reactions Weekly | 2021
Ipilimumab/nivolumab
Abstract
Sarcoid-like reaction: case report A 40-year-old man developed sarcoid-like reaction (SLR) during treatment with nivolumab and ipilimumab for metastatic melanoma [dosages and routes not stated]. The man was referred to the clinic for evaluation of a right-sided neck swelling. The swelling had progressively increased in size over a 6 month period and was associated with malaise and fatigue. His medical history was significant for uncontrolled diabetes mellitus type 2, hyperlipidaemia, chronic kidney disease, hypertension and tobacco use. Based on the clinical presentation and laboratory findings, metastatic melanoma was considered. He initially underwent stereotactic radiosurgery for the solitary brain metastases. Subsequently, he started receiving treatment with nivolumab. After receiving 4 cycles, ipilimumab therapy was added to potentially achieve a better response since the neck mass remained palpable. A repeat whole-body positron emission tomogram/CT (PET/CT) scan after 7 cycles of treatment showed an increase in hypermetabolic activity in the right supraclavicular area and development of hypermetabolic activity in the hilar, infraclavicular and mediastinal regions. Subsequently, a next-generation sequencing analysis showed positive results for BRAF V600E mutation. Therefore, the man’s therapy with nivolumab and ipilimumab was stopped, and he started receiving a combination BRAF/ mitogen-activated protein kinase inhibitor therapy. On subsequent follow-up visit, the laboratory testing showed a serum calcium level of 13.3 (hypercalcaemia), a high normal calcitriol level, a low parathyroid hormone level and an elevated angiotensinconverting enzyme (ACE) level. After 2 months of treatment with the combination BRAF/mitogen-activated protein kinase inhibitors, a repeat CT showed a significant decrease in size of the neck mass; however, mediastinal and hilar lymph nodes increased in size. Subsequently, he underwent bronchoscopy, and the pathology from the fine needle aspiration of the enlarged mediastinal lymph node revealed giant cells, epithelioid histiocytes and lymphocytes, which was consistent with a granulomatous process. Based on the laboratory findings, a diagnosis of nivolumab and ipilimumab-induced SLR was made. Therefore, he was admitted to the hospital for a brief period for hypercalcaemia and acute on chronic renal failure. He received treatment with unspecified steroids, bisphosphonates and hydration. Subsequently, laboratory testing showed normalisation of calcium and ACE levels. On subsequent follow-ups, PET scan and CT scan of the chest revealed radiological improvement.