摘要
目的探讨程序性死亡蛋白1(PD-1)及程序性死亡配体1(PD-L1)抑制剂所致免疫相关肺炎的临床特征、诊断、治疗和预后。方法回顾性分析上海长征医院收治的1例晚期食管癌患者使用PD-1抑制剂pembrolizumab并在停药后出现免疫相关肺炎的临床资料,并对相关文献进行复习。结果患者男,64岁,食管癌术后出现腹腔淋巴结转移,二线给予Keytruda(200mg,静脉注射,每3周1次)治疗8个周期,腹腔转移性淋巴结缩小,用药期间未见明显不良反应。停用Keytruda4周后,出现胸闷、气急,胸部CT显示双肺弥漫磨玻璃影、网格状影。抗细菌治疗无效,使用足量激素2周仍未见明显改善,激素减量并加用吡非尼酮2个月后双肺间质性改变明显改善,但转移性腹腔淋巴结再次增大。文献复习PD-1抑制剂所致免疫相关肺炎,发病的中位时间为用药后28个月,最常见的临床表现为气短、呼吸困难,发热相对少见;最常见的影像表现为双肺多发磨玻璃影、网格状影、实变影;病理类型以机化性肺炎为主;轻症患者足量激素治疗后缓慢规律减量预后较好,重症患者可联合免疫抑制剂治疗,3级以上病例病死率高。结论需要提高对PD-1/PD-L1抑制剂所致免疫相关肺炎的认识,停药后仍需定期随访,监测各系统免疫相关不良反应。
Objective To inrestigate the clinical mainfestations,diagnosis,treatment and prognosis of immune related pneumonia caused by programmed cell death 1(PD-1)and programmed death ligand-1(PD-LI)inhibitors.Methods The data of the patient with advanced esophageal cancer admitted to Shanghai Changzheng Hospital who used PD-1 inhibitor pembrolizumab and developed immune related pneumonia after drug withdrawal was retrospectively analyzed,and related literatures were reviewed.Results A 64 year old male patient with metastatic abdominal lymph nodes after esophageal cancer surgery received second line treatment with Kcytruda(200 mg,intravenous injection,once every three weeks)for eight cycles.The metastatic abdominal lymph nodes contracted.There was no obvious adverse reactions during the treatment.After four weeks of discontinuation of Kcytruda,chest tightness and shortness of breath appeared,and chest CT showed diffuse ground glass shadows and grid shadows.Antibacterial treatment was ineffective.There was no significant improvement after sufficient hormones for two weeks.The interstitial changes in both lungs significantly improved after two months,but the metastatic abdominal lymph nodes increased again.The literatures reviewed showed median time of immune related pneumonitis was 2.8 months after administration.The most common clinical manifestations were shortness of breath, dyspnea, and relatively rare fever. Imaging features were commonly ground glass shadow, grid like shadow, solid shadow. Pathological type was mainly organizing pneumonia. The mild patients with adequatc hormone therapy had a better prognosis, severe patients received combined immunosuppressive therapy. There was higher fatality rate for eases above grade 3. Conclusions It is necessary to improve the understanding of immune related pneumonia caused by PD-1/PD-LI inhibitors.After drug withdrawal, regular follow up is required to monitor immune related adverse reactions of various systems.
作者
陈杨
方正
Chen Yang;Fang Zheng(Department of Respiratory and Critical Care Medicine,Shanghai Changzheng Hospital,Shanghai 2000031,China)
出处
《国际呼吸杂志》
2020年第9期684-688,共5页
International Journal of Respiration
关键词
免疫相关肺炎
程序性死亡蛋白-1抑制剂
临床特征
Immune-related pneumonitis
Programmed cell death-1 inhibitor
Clinical characteristics
