Endocrine Abstracts

Endocrinopathies are one of the most common side effects induced by immunotherapy. The side effects result from the activation of immune system, which affects not only cancerous but also healthy body cells. In most cases, only one endocrinopathy occurs, but in our presented case we describe multiple endocrinopathies that occurred to a one person. 53-years-old male patient was referred to the Emergency department due to severe hyperglycemia (37.13 mmol/l) and the following symptoms: frequent urination, thirst, general weakness. New-onset diabetes was diagnosed and the patient was admitted to the Department of Endocrinology. After clarification of past medical history oncological disease emerged. In 2013, metastatic right kidney cancer was diagnosed (the tumor was spread to the lungs), the right nephrectomy was performed. Histopathological analysis confirmed clear cell renal cell carcinoma (ccRCC, pT3aG3). Systemic therapy with Sunitinib has been initiated. During the course of treatment, in 2016, hypothyroidism appeared, LT4 treatment was necessary. In 2020, for the reason of disease progression, immunotherapy with nivolumab, as a second line treatment, was initiated and stereotactic radiotherapy for paraaortic lymph nodes was applied. In the Department of Endocrinology, for the treatment of newly diagnosed diabetes mellitus intensive insulin therapy was chosen (HbA1c 18.7%, anti-IA2 1.0k U/l, n 0-7.5k U/l, anti-GAD 0.57k U/l, n 0-5; suspected immunotherapy-induced autoimmune diabetes mellitus). Depending on the patient medical history, was decided to consider other possible immunotherapy-induced endocrinopathies. After additional investigation hypopituitarism, secondary adrenal insufficiency was confirmed (ACTH 0.4 pmol/l, n 1.63-14.15, morning cortisol 47.1 nmol/l, n 147-726). Hydrocortisone replacement therapy was started immediately. Repeated blood tests revealed low levels of testosterone (T 2.22→3.23, n 9.08-30.1). The patient completed an international index of erectile function (IIEF) questionnaire and was diagnosed with mild to moderate erectile dysfunction. Mixed hypogonadism was confirmed (hypogonadism due to hypothalamic/pituitary and testicular dysfunction; LH 4.0 IU/I n 1.7-11.2, FSH 10.2 IU/I n 2.1-18.6), testosterone replacement therapy was prescribed. During inpatient treatment, headache and visual disturbances appeared. In assessing the course of the disease, tests results, despite the fact that no changes in the pituitary gland were seen after MRI, hypohysitis was diagnosed. The patient was discussed at multidisciplinary team meeting and it was decided that after adjusting the patient’s condition, immunotherapy can be resumed, continuing the active follow up at the Department of Endocrinology.

It is very important to monitor patients throughout and after the treatment of immunotherapy for possible side effects that can lead to serious, life-threatening complications if not diagnosed in time.