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Sarcoid-like irAE Management — SCE Medical Oncology MCQ

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ModerateMelanoma & SkinSarcoid-like irAE ManagementSCE Medical Oncology

A 62-year-old man with metastatic melanoma on nivolumab develops new-onset granulomatous inflammation in the lung mimicking sarcoidosis on PET-CT (bilateral hilar and mediastinal FDG-avid lymphadenopathy). Biopsy confirms non-caseating granulomata without malignant cells. Should immunotherapy be stopped?

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Correct answer: E — Not necessarily — sarcoid-like reactions are usually managed without ICI discontinuation; asymptomatic cases can be observed; symptomatic cases may need low-dose corticosteroids while continuing ICI

ICI-related sarcoidosis-like granulomatous reactions occur in approximately 5-7% of patients and can mimic metastatic disease on PET-CT. Crucially, biopsy is essential to distinguish granulomatous inflammation from metastasis. Asymptomatic sarcoid-like reactions can be observed while continuing ICI. Symptomatic cases may require low-dose prednisolone (10-20 mg). ICI continuation is usually possible. This irAE may paradoxically indicate good immune activation and has been associated with better tumour outcomes.

Reference: ESMO 2024 irAE Management; Chopra et al Cancer 2018