Hepatotoxicity of immune checkpoint inhibitors: a histology study of seven cases in comparison with autoimmune hepatitis and idiosyncratic drug-induced liver injury

• Published in: Modern pathology 2018-06, Vol.31 (6), p.965-973
• Main Authors: Zen, Yoh, Yeh, Matthew M.
• Format: Article
• Language: English
• Subjects: 13/51; 631/250/38; 692/699/1503/1607/2749; Abscesses; Adult; Aged; Aged, 80 and over; Antineoplastic Agents, Immunological - adverse effects; Antineoplastic Agents, Immunological - therapeutic use; Antinuclear antibodies; Autoimmune diseases; Bile; Bile ducts; Cancer; Cancer immunotherapy; Carcinoma, Squamous Cell - drug therapy; Carcinoma, Squamous Cell - pathology; CD20 antigen; CD3 antigen; CD4 antigen; CD8 antigen; Cell activation; Chemical and Drug Induced Liver Injury - pathology; Corticosteroids; Enzymes; Female; Gangrene; Hepatitis; Hepatitis, Autoimmune - pathology; Hepatotoxicity; Histology; Humans; Hyperbilirubinemia; Immune checkpoint inhibitors; Immunoglobulin G; Immunosuppression; Immunotherapy; Immunotherapy - adverse effects; Laboratory Medicine; Liver; Liver - pathology; Liver diseases; Lymphocytes B; Lymphocytes T; Male; Medicine; Medicine & Public Health; Melanoma - drug therapy; Melanoma - pathology; Middle Aged; Monoclonal antibodies; Necrosis; Pathology; Skin Neoplasms - drug therapy; Skin Neoplasms - pathology; Targeted cancer therapy; Tongue Neoplasms - drug therapy; Tongue Neoplasms - pathology; Young Adult
• ISSN: 0893-3952; 1530-0285
• DOI: 10.1038/s41379-018-0013-y

The adverse effects of immune checkpoint inhibitors in various organs may be attributed to immune-mediated processes triggered by disrupted self-tolerance; however, it remains unclear whether they are similar or dissimilar to classic organ-specific autoimmune diseases. The present study aimed to compare clinicopathologic features between checkpoint inhibitor-induced liver injury and acutely presenting autoimmune hepatitis or idiosyncratic drug-induced liver injury. Seven patients treated with nivolumab (n = 5) or ipilimumab (n = 2) presented with liver dysfunction a median of 41 days (range 21–120) after the initiation of immunotherapy. All patients had elevated liver enzymes, whereas hyper-bilirubinemia was less common. None of the patients had antinuclear antibodies or IgG elevations. Stopping the immunotherapy and additional immunosuppression with corticosteroids normalized or decreased liver enzymes in all patients treated. Histologically, all biopsies showed predominantly lobular hepatitis with milder portal inflammation. Centrilobular confluent necrosis and plasmacytosis were observed in a single case, and were markedly less common and milder than those in autoimmune hepatitis (p = 0.017 and p < 0.001, respectively). Bile duct injury, micro-abscesses, and extramedullary hematopoiesis were also found in one case each. Immunostaining revealed the presence of large numbers of CD3+ and CD8+ lymphocytes, whereas CD20+ B cells and CD4+ T cells were fewer in checkpoint inhibitor-induced liver injury than in autoimmune hepatitis or drug-induced liver injury. In conclusion, liver injury caused by cancer immunotherapy shares some features with injury of autoimmune hepatitis; however, there are obvious differences between the two conditions. Checkpoint inhibitor-induced liver injury may represent an immune-mediated, less zone-selective hepatocyte necrosis not requiring the strong activation of helper T cells and immunoglobulin production.