Memorial Sloan-Kettering Cancer Center New York, NY
Award: Presidential Poster Award
Deepika Satish, MD, Hans Gerdes, MD, David Faleck, MD; Memorial Sloan-Kettering Cancer Center, New York, NY
Introduction: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of many metastatic cancers but are associated with a variety of immune-related adverse events (irAE). Diarrhea is a frequent irAE, which affects up to 35% of ICI-treated patients. While diarrhea is typically attributed to ICI-related colitis, steatorrhea secondary to exocrine pancreatic insufficiency (EPI) has been reported as well. Methods: We describe a retrospective cohort of patients with metastatic cancer treated with an ICI who developed EPI at a tertiary care cancer center in New York City between 2011 and 2020. A database query was performed for all ICI-treated patients who subsequently had an ICD code for exocrine pancreatic insufficiency or for steatorrhea, or who were prescribed pancrelipase. Exclusion criteria included pancreas cancer, pancreatic metastases, history of pancreatic surgery, pancrelipase use prior to ICI, and patients without clearly documented symptoms of EPI. Individual patient charts were reviewed to identify patients in whom there was a clear description of steatorrhea, which promptly improved upon initiation of pancrelipase. Results: Nine patients developed EPI a median of 589 (IQR 149-796) days after the first dose of ICI. Median duration of ICI use preceding the development of EPI was 284 (IQR 128-516) days. Seven (78%) patients had an irAE prior to the onset of EPI, of which 4 (44%) patients had multiple irAEs.
Six (67%) of the nine patients had elevated lipase levels prior to presenting with EPI, though only two (22%) had prior episodes of clinical pancreatitis. Fecal fat and/or elastase was tested in seven (78%) of the nine patients and was abnormal in all those who were tested. Imaging characteristics of chronic pancreatitis were not noted on cross-sectional imaging (CT or MRI) for any of the nine patients. Five (56%) patients had a prior smoking history. One (11%) patient had a history of alcohol abuse without a history of pancreatitis, while five (56%) patients endorsed social alcohol consumption. Discussion: EPI is a rare irAE that may develop after ICI use, even in the absence of prior clinical pancreatitis. Clinicians should consider this as a distinct differential diagnosis for ICI-related diarrhea, especially when the diarrhea presents later or even after the course of treatment.
Characteristics of Patients Who Developed EPI After Use of an ICI
Disclosures: Deepika Satish indicated no relevant financial relationships. Hans Gerdes indicated no relevant financial relationships. David Faleck indicated no relevant financial relationships.