Author(s)
Karen K. Hoi, BS
Tianhong Li, MD, PhD
Li Lei, MD, PhD
Arnaud F. Bewley, MD
Maggie A. Kuhn, MD
Affiliation(s)
University of Michigan Medical School; UC Davis Department of Otolaryngology-Head and Neck Surgery;
Abstract:
Educational Objectives: At the conclusion of this presentation, the participants should be able to identify etiologies of a pharyngeal mass in a non-head and neck cancer patient receiving immune checkpoint therapy. Participants should be able to recognize that immune related adverse events can occur throughout the body and can mimic malignancy. Furthermore, participants should be able to describe the advantages and limitations of in-office biopsy for ruling out aerodigestive malignancy.
Objectives: To describe a novel case of activated lymphocyte infiltration of the hypopharynx associated with cervical lymphadenopathy in a patient treated with anti-PD-L1 therapy for triple negative breast cancer (TNBC).
Study Design: Case report.
Methods: The patient's presentation, clinical course, management, and followup findings are reported. A review of literature on immune related adverse events (irAE) in the pharynx is summarized. Considerations for diagnosis and management of similar presentations are presented.
Results: A 48 year old female with TNBC who previously underwent neoadjuvant chemotherapy, lumpectomy, adjuvant radiation, gamma knife, two surgical brain resections, and 6 cycles of pembrolizumab for metastatic disease was started on second line systemic therapy with atezolizumab and Abraxane. After 12 cycles, she reported dysphonia, odynophagia, weight loss, chills, sweats and hemoptysis. PET-CT demonstrated new uptake around the right pyriform sinus extending across midline with hypermetabolic right level 1-3 cervical lymph nodes. Flexible laryngoscopy revealed fullness and obliteration of the right pyriform sinus concerning for malignancy. In-office biopsy through a channeled laryngoscope demonstrated inflammatory and reactive changes. FNA biopsy of a right level 2 lymph node showed a lymphocytic population without malignant cells. Atezolizumab was discontinued. Symptoms improved after six weeks. PET-CT six months later showed resolution of hypopharyngeal and lymph node activity.
Conclusions: Lymphocytic infiltration of the head and neck is an unreported irAE. Biopsy is useful in differentiating malignancy from irAE. A high suspicion and awareness that irAE may occur anywhere in the body is necessary in order to guide timely diagnosis and management.