Total Abdominal Colectomy for Management of Refractory Immune Checkpoint -Induced Colitis

Document Type

Conference Proceeding

Publication Date

5-21-2025

Publication Title

Surg Endosc

Keywords

cytotoxic T lymphocyte antigen 4, immune checkpoint inhibitor, immunoglobulin G4, infliximab, ipilimumab, nivolumab, nonsteroid antiinflammatory agent, adult, case report, Caucasian, colectomy, colitis, computer assisted tomography, conference abstract, conservative treatment, controlled study, diarrhea, drug combination, drug therapy, end ileostomy, human, laparotomy, male, metastatic melanoma, multiple cycle treatment, overall survival, peritonitis, pneumoperitoneum, risk factor, side effect, sigmoidoscopy, surgery, therapy

Abstract

Immune checkpoint inhibitors, such as ipilimumab and nivolumab are changing treatment paradigms and improving overall survival for a myriad of cancers. As with all treatments, adverse side effects become more apparent with greater exposure. Ipilimumab activates the immune system by targeting CTLA-4, a protein receptor that downregulates the immune system. Nivolumab is a human IgG4 monoclonal antibody that blocks PD-1. The combination of both is commonly used in metastatic melanoma. Using both increases the rate of immune-mediated colitis (1). The reported incidence of colitis is about five times greater with ipilimumab than nivolumab and is 13.6% with combination therapy (1). We present a case of a 69-yearold male with metastatic melanoma who developed colitis after starting combination therapy, leading to a total abdominal colectomy. Initially, he underwent a sigmoidoscopy and was conservatively treated with infliximab and steroids but later returned to the hospital with worsening diarrhea and signs of peritonitis. A CT scan revealed pneumoperitoneum suggestive of a perforated viscus. During exploratory laparotomy, multiple areas of friable tissue and perforations in the sigmoid colon were found, resulting in a total abdominal colectomy with end ileostomy. The patient has since recovered well post-surgery. We discuss the risk factors for such extensive colitis including failure of appropriate medical management, greater likelihood of immune-mediated colitis in Caucasian/white patients, those treated with an anti-CTLA4 based regime, NSAID use, and those with prior history of checkpoint inhibitor induced colitis (3). We identify the need for additional studies in which patients will likely fail medical management of immune mediated colitis caused by checkpoint inhibitors. As these medications become the standard of care, it is important to determine which patients may be refractory to conservative management of their immune mediated colitis.

Volume

31

First Page

S317

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