Discussion: Immunotherapy is an emerging treatment which has been found in randomized controlled trials to increase survival and progression-free periods for a number of solid tumors. Immunotherapy promotes T cell activity to generate an antitumor effect, however studies have found as many as 85% of treated patients experienced toxicities including colitis, renal dysfunction and hepatitis. Ipilimumab and nivolumab have been associated with hepatic infiltration of T cells, resulting in immune-mediated hepatitis affecting 13% of patients, a higher rate than when these agents are used individually. This patient experienced acute hepatic failure in the absence of previous hepatic disease suggesting that the dual agents may have synergistic hepatotoxicity. Immune related hepatitis is typically treated with high dose corticosteroids. Here we report an unusual case of fulminant hepatic failure secondary to dual immunotherapy which did not respond to steroids.
Conclusions: It is important to recognize immune related organ damage in patients undergoing immunotherapy for solid tumors. Early intervention with high dose steroids may reverse immune mediated damage in some cases. Other therapeutic options include mycophenolate and TNF inhibitors. Larger studies will be necessary to investigate if patients may benefit from evaluation for pre-existing liver disease prior to initiating dual immunotherapy or routine liver enzyme monitoring while undergoing therapy.
To cite this abstract:Firoozan, S; Boparai, R . FULMINANT LIVER FAILURE CAUSED BY DUAL IMMUNOTHERAPY FOR MALIGNANT MELANOMA. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 444. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/fulminant-liver-failure-caused-by-dual-immunotherapy-for-malignant-melanoma/. Accessed January 19, 2020.