Nivolumab
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Erythroblastopenia: case report A 55-year-old woman developed erythroblastopenia during treatment with nivolumab for ulcerated acrolentiginous melanoma of the right foot. The woman, who had a medical history of smoking and peripheral artery disease treated with aspirin, was diagnosed with ulcerated acrolentiginous melanoma of the right foot. She started receiving treatment with nivolumab 240mg every 2 weeks [route not stated] as adjuvant treatment in May 2019. Prior to starting treatment, her haemoglobin (Hb) level was 12.7 g/dL and was unchanged for 1 month. Two months after starting nivolumab, on day 55, Hb level was 11.8 g/dL and suddenly dropped to 7.2 g/dL on day 84. Additionally, her platelet count dropped to 108 G/L and then to 93 G/L on day 86, prior to returning to normal on day 128. Transient and moderate leucopenia at 1.5G/L was also noted on day 86. The woman was admitted and was first transfused with 2 packs of RBCs, followed by transfusions twice a week thereafter. Despite receiving a total of 29 packed RBCs with a nadir at 4.3 g/dL and a thorough work-up to find a source of bleeding, her Hb remained persistently low. She presented a non-regenerative anaemia with a low reticulocytes count. No iron, vitamin B12 or folate deficiency was identified. Haptoglobin level dropped on day 119 and bilirubin level was at some point slightly supranormal. Direct Coombs test was positive for IgG and C3. Two bone marrow examinations were remarkable for the lack of erythroblastic cell line, without dysplasia or abnormal cells. These findings were consistent with pure red cell aplasia (PRCA; erythroblastopenia) secondary to nivolumab. Her treatment with nivolumab was discontinued on day 98 after the eighth cycle, and she started receiving treatment with an unspecified oral corticosteroid on day 135, without efficacy. Her erythroblastopenia persisted and she remained transfusion-dependent for almost two additional months. On day 184, ciclosporin was introduced with packed RBC transfusion. The treatment with ciclosporin was significantly effective, with Hb level rising to 9 g/dL on the third day and reticulocytes count at 12 46 932/mm3. Two weeks after starting ciclosporin, on day 198, Hb concentration returned to pre-nivolumab levels of 11.7 g/dL. She was discharged with ciclosporin and unspecified corticosteroids on day 278, both with a slow taper until March 2020. Ciclosporin was first tapered in January 2020, and then every 7–10 days until March2020. Corticosteroids were tapered every month between October 2019 and March 2020. In January 2020 (on day 226), her Hb level was 14.4 g/dL. Nine months after nivolumab discontinuation, there was no erythroblastopenia relapse, and she remained free of melanoma progression without any cancer treatment. Gerard A, et al. Case Report: Successful Treatment of Steroid-Refractory Immune Checkpoint Inhibitor-Related Pure Red Cell Aplasia With Cyclosporin. Frontiers in 803506023 Oncology 10: 28 Aug 2020. Available from: URL: http://doi.org/10.3389/fonc.2020.01760
0114-9954/20/18
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