Nivolumab-induced immune thrombocytopenia in a patient with malignant pleural mesothelioma

Our plain-English summary of Nivolumab-induced immune thrombocytopenia in a patient with malignant pleural mesothelioma, by J. Sakakibara-Konishi, M. Sato, M.T. Sato, et al (Respiratory Medicine Case Reports, 2020).

The study

• Authors: J. Sakakibara-Konishi, M. Sato, M.T. Sato, K. Kasahara, M. Onozawa, H. Mizugaki, E. Kikuchi, H. Asahina, N. Shinagawa, S. Konno
• Journal: Respiratory Medicine Case Reports
• Published: 2020;31:101170
• Type of article: Case report
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma (MPM) is a rare and highly aggressive tumor. Nivolumab showed durable antitumor effect in patients with recurrent MPM and was approved for those patients in Japan in 2018. Immune related adverse event (irAE) is occurred in various organs and is suggestive to be related to better outcome of nivolumab. Frequency of hematological irAE is low and there are few reports about hematological irAE and association between irAE and outcome of nivolumab in patients with MPM. We present a case of recurrent MPM who responded to nivolumab treatment and experienced nivolumab-induced immune thrombocytopenia (ITP). Although high dose dexamethasone was administered and platelet count increased transiently, re-administration of dexamethasone was required to maintain normal count of platelet. The careful and intensive management of ITP treatment is necessary in cases who show no response or relapse to initial glucocorticoids treatment. This is the first report about nivolumab-induced ITP and association with response to nivolumab in MPM.

© 2020 The Authors. Published by Elsevier Ltd.

In plain English

This case report described one patient, a 60-year-old man in Japan with malignant pleural mesothelioma of the epithelioid subtype, treated at Hokkaido University Hospital. The article did not describe any asbestos exposure for this patient. He had surgery (extrapleural pneumonectomy) in March 2013 and, after the cancer returned, several rounds of chemotherapy. In September 2018 he began nivolumab, an immune checkpoint inhibitor drug, and his tumors shrank. In January 2019, after six cycles, his platelet count fell suddenly to 24000 per microliter. It then fell to 12000 per microliter even though nivolumab was stopped, and he developed bleeding under the skin. An antinuclear antibody test was positive and a platelet-associated antibody level was raised. The authors determined that the low platelet count was caused by nivolumab. A 4-day course of dexamethasone raised his platelets only temporarily. A second course followed by platelet transfusions produced a sustained response. His mesothelioma progressed four months after his last nivolumab dose. The authors concluded that patients who relapse or resist initial steroid treatment need careful management and follow-up.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 60-year-old man with malignant pleural mesothelioma (epithelioid subtype, pathological stage III), treated at Hokkaido University Hospital, Sapporo, Japan, from 2013 to 2019; no history of autoimmune disease
• Exposure: The exposure studied was the drug nivolumab (240 mg every 2 weeks, from September 2018), given after earlier chemotherapy for recurrent disease. The patient's asbestos exposure was not reported.
• Main results:
  • After nivolumab, the mediastinal lymph nodes and pericardial metastases shrank and the fluid in the abdomen decreased.
  • In January 2019, after six cycles of nivolumab, the patient's platelet count suddenly fell to 24000/μL.
  • After nivolumab was stopped, the patient's platelet count fell further to 12000/μL and he developed subcutaneous bleeding.
  • The patient's antinuclear antibody test was positive. His platelet-associated IgG rose to 555, against a stated normal range below 46.
  • The authors determined that the thrombocytopenia was induced by nivolumab.
  • Dexamethasone 33 mg for 4 days raised the patient's platelets temporarily to 158000/μL. Seven days later they fell again to 21000/μL.
  • A second dexamethasone course followed by platelet transfusions led to a sustained rise in the patient's platelet count.
  • The patient's mesothelioma progressed four months after his last nivolumab treatment.
• The authors' conclusion: The authors concluded that, although nivolumab-induced ITP is rare, systematic diagnosis and treatment are required. They added that careful management and follow-up should be considered in patients who relapse or resist initial glucocorticoid treatment. They described this as the first report of nivolumab-induced ITP associated with response to nivolumab in a patient with MPM.

Topics

Medical terms in this study, explained in our Lexicon: Nivolumab (Opdivo), Pleural Mesothelioma.

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