Tecentriq Linked to LEMS in Man With Non-Small Lung Cancer

Rare case of patient, in remission, developing LEMS after 4 treatment cycles

Patricia Inácio, PhD avatar

by Patricia Inácio, PhD |

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A possible first case of a man with non-small cell lung cancer (NSCLC) developing Lambert-Eaton myasthenic syndrome (LEMS) after being treated with Tecentriq (atezolizumab) has been reported in Pennsylvania.

This case adds to prior evidence linking the use of Tecentriq, as well as the immunotherapies Opdivo and Yervoy, with an increased risk of LEMS.

“Atezolizumab [Tecentriq] treatment can result in the development of autoimmune conditions such as LEMS which could be life-threatening if not recognized and treated promptly,” the scientists wrote.

The case was described in the study, “Lambert Eaton Myasthenic Syndrome (LEMS) Secondary to Atezolizumab in a Patient with Squamous Cell Carcinoma of the Lung,” that is to be presented at the 64th ASH Annual Meeting and Exposition in New Orleans, Louisiana, on Dec. 10–13.

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A rare autoimmune disease, LEMS is caused by erroneous immune system attacks against voltage-gated calcium channels (VGCCs), which are found on nerve cells and play a key role in nerve-muscle communication.

The majority of LEMS cases are linked to an aggressive form of lung cancer called small cell lung cancer (SCLC). Standard treatment for these patients consists mostly of chemotherapy. But combining chemotherapy agents with immune checkpoint inhibitors, a type of immunotherapy, is known to help prolong survival.

Immune checkpoint inhibitors, such as Tecentriq, target proteins at the surface of immune cells as “off switches” to hamper the immune system’s ability to detect and destroy cancer cells. As such, Tecentriq is capable of restoring immune surveillance.

But immune checkpoint inhibitors harness the power of the body’s immune system to fight off cancer, and they may cause potential immune-related side effects.

This report describes a 67-year-old man with squamous cell lung cancer (SCC), a type of NSCLC, who was treated with Tecentriq and a short time later developed LEMS.

A few case reports exist where [LEMS] has been described in association with other immunotherapy drugs for lung cancer … but rarely with atezolizumab” or in a person with SCC, the scientists noted.

The patient, with an “extensive” history of smoking, was found to have a mass in the right lower lung during a routine lung cancer screening CT scan. Further imaging tests and a lung biopsy confirmed SCC, at stage 3A.

The tumor was surgically removed from the lung’s lobe, along with a few chest lymph nodes. He received four cycles of chemotherapy (docetaxel and cisplatin) and was started on maintenance treatment with Tecentriq.

CT scans showed his cancer in complete remission, with no signs of recurrence. However, shortly after his fourth Tecentriq treatment cycle, the man came to the hospital’s emergency room with complaints of double vision, facial droop, and difficulty holding his neck upright.

He had shortness of breath while lying flat, and a physical examination also found muscle weakness. Brain scans showed no evidence of a stroke or cancer spread (metastasis).

Neurologists considered his symptoms to be consistent with an autoimmune reaction due to Tecentriq. He underwent blood work for several types of autoantibodies, and he was prescribed oral pyridostigmine (60 mg, three times daily) and the steroid prednisone (40 mg, twice daily).

After failing to respond properly to these medications, the man was started on plasmapheresis or plasma exchange — a procedure that involves replacing a person’s plasma, the non-cellular part of blood.

His blood work ultimately came back positive for VGCC antibodies, consistent with a LEMS diagnosis.

After a total of five plasmapheresis sessions, his muscle weakness eased “remarkably” and his breathing improved. He stopped using Tecentriq and was discharged while tapering off steroid treatment.

“Our case is unique since LEMS occurred as a result of immunotherapy with atezolizumab in a patient with squamous cell carcinoma (SCC) of the lung,” the scientists wrote, and particularly in a cancer patient in remission.