Infection was excluded on the basis of clinical findings. Figure 4b. ICI therapy can also be used with nivolumab, a PD-1 inhibitor, and ipilimumab, a combination that has FDA approval for the treatment of colorectal cancer and renal cell carcinoma. Although not specifically addressed in the American Society of Clinical Oncology Practice Guideline, recurrent pneumonitis is often treated with methods similar to those used in the treatment of the initial occurrence. Figure 9c. In the last decade, the introduction of immunotherapy has revolutionized the management and treatment approaches for a number of malignancies. Patients treated with checkpoint inhibitors may show variable computed tomography (CT) features on follow-up imaging, and it is unclear how reliable conventional response criteria are to determine patient management and outcomes. No fevers or raised septic markers. Imaging. However, PET lacks in diagnostic specificity in this scenario, given the potential overlap of hypermetabolic activity with malignancy and infectious processes. Figure 9a. irAE risk has been shown to have a dose-dependent relationship for CTLA-4 inhibitors, but this has not been consistently observed in PD-1 and/or PD-L1 inhibitors (19). We describe the findings of a SARS-CoV-2 infection on PET/CT with F-FDG in a 51-year-old man with metastatic renal cell carcinoma under treatment with nivolumab. The patient previously underwent radiation therapy for multiple left posterior rib metastases. (a) Axial CT image in a 65-year-old man undergoing ipilimumab therapy for metastatic melanoma shows large bilateral lower lobe pleural-based consolidative and ground-glass opacities (arrows). Recurrent pneumonitis pattern, location of involvement, and severity may vary compared with those at initial presentation. APC = antigen-presenting cell, B7-1/2 = ligands B7-1 and B7-2. From the Department of Radiology, Duke University Medical Center, Durham, NC (K.R.K. Six weeks after starting nivolumab therapy, the patient presented with severely worsening dyspnea. Reported recurrence rate after rechallenge is 17%–29% (21,25,31). The diagnosis of immune-related pneumoni-tis was based on typical clinical features and on new typical imaging changes such as ground glass opacities in chest com-puted tomography (CT) scan. Figure 6c. For example, pembrolizumab, a PD-1 inhibitor, has FDA approval as frontline treatment of advanced epidermal growth factor receptor and anaplastic lymphoma kinase wild-type non–small cell lung cancer in which tumors have at least 50% PD-L1 expression. Immunotherapy was subsequently held, and steroid therapy was administered. Figure 1b. HP pattern may also mimic other small airways processes such as respiratory and follicular bronchiolitis, which are classically associated with smoking and underlying connective tissue or autoimmune disease history, respectively. The results indicated the utility of a radiographic pattern–based approach as a guide for patient treatment and monitoring for immunotherapy-related pneumonitis. Previously, the bronchiolitis pattern may have been overlooked as a distinct pneumonitis pattern given its identical appearance to infectious and other inflammatory causes of bronchiolitis. APC = antigen-presenting cell, B7-1/2 = ligands B7-1 and B7-2. HP pattern in a 52-year-old woman who underwent nivolumab therapy for stage IV lung adenocarcinoma. Purpose: Investigate the clinical characteristics, radiographic patterns, and treatment course of PD-1 inhibitor–related pneumonitis in advanced cancer patients. ■ Illustrate the imaging patterns of ICI therapy–related pneumonitis and related clinical classification schemes. (a) Baseline axial chest CT image shows a medial left lower lobe lung mass with surrounding ground-glass halo sign (arrow), a finding corresponding to adenocarcinoma. (c) Axial chest CT image obtained 1 month later after withholding ICI therapy and administering steroid therapy shows residual, although significantly improved, airspace disease (arrows). Immune check… Background: Nivolumab is a novel immunotherapy that was recently approved for treatment of advanced non-small-cell lung cancer (NSCLC). Higher rates of pneumonitis have been observed in non–small cell lung cancer and renal cell carcinoma versus those of melanoma (22). In the setting of a requisite costimulatory interaction such as the CD28 receptor, T-cells become activated and further activate a cascade of antitumor activity (3,4). Immunotherapy was subsequently held, and steroid therapy was administered. GI = gastrointestinal. Described findings of HP pattern mirror those typically found in cases of subacute HP depicted in other settings. cases.29 On CT, radiographic findings might be variable, with reported patterns including cryptogenic organising pneumonia, nonspecific interstitial pneumonia, hyper sensitivity pneumonitis, and bronchiolitis (figure 217,30–33). Despite researchers’ increasing awareness and experience with ICI therapy–related pneumonitis, large-scale studies categorizing the various radiologic patterns are somewhat limited. OP pattern most commonly manifests as patchy bilateral opacities with a peripheral or peribronchovascular predominance, often with a mid- to lower-lung predominance (Fig 3). Going forward, given the potential complexity of diagnosis and management of ICI therapy–related pneumonitis, radiologists must work in conjunction with a broader multidisciplinary team to provide optimal care for these patients. Figure 8b. Several distinct radiographic patterns of pneumonitis have been observed: (a) organizing pneumonia, (b) nonspecific interstitial pneumonia, (c) hypersensitivity pneumonitis, (d) acute interstitial pneumonia–acute respiratory distress syndrome, (e) bronchiolitis, and (f) radiation recall pneumonitis. Minimal subpleural ground-glass opacities in the right lower lobe were thought to be dependent atelectasis. Patients with suspected pneumonitis should undergo initial clinical assessment with physical examination and pulse oximetry. (a) Axial chest CT image obtained 5 months after starting nivolumab therapy shows diffuse centrilobular ground-glass nodules (arrows). However, suspicion for this entity as a distinct pneumonitis pattern should be raised in the absence of infectious symptoms and be confirmed at imaging by documenting resolution of findings after withholding therapy or after a trial of steroid therapy. (c) Axial chest CT image obtained 5 days later after further respiratory decompensation (despite withholding ICI therapy and initiating intravenous steroid therapy) shows increasing severity and confluence of ground-glass opacities (arrows), with little intervening normal lung parenchyma. Figure 10a. The role of PET in the diagnosis and follow-up of ICI therapy–related pneumonitis is unclear, although there have been several reports of pneumonitis at PET/CT (28–30). (c) Axial chest CT image obtained 5 months after discontinuation of therapy shows minimal residual (although markedly improved) pneumonitis (arrow) in the left lower lobe. Outside of the lung, the skin is a common site of involvement. The airways are unremarkable. Immunotherapy-induced pneumonitis - metastatic melanoma. Chest radiography can be considered to track evolving pneumonitis findings. Because of the greater experience with larger clinical trials involving ICI therapies and emerging toxicity profiles, different patterns with respect to presentation, imaging findings, and management have become apparent between ICI therapy–related and conventional chemotherapy-related pneumonitis. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Some patients were diagnosed with concomitant patterns, and a distinctive pattern was not identified in 36% of cases. (c) Follow-up axial chest CT image obtained 3 months later after withholding ICI therapy and administering steroid therapy shows resolved pneumonitis. Margins, simulating findings of hp pattern can manifest with new masslike consolidative may. 1 ) ( 31 ) for a number of malignancies temsirolimus are specific inhibitors of immunotherapy pneumonitis ct and used... 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