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Granulomatous ICI Hepatitis — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyGranulomatous ICI HepatitisSCE Medical Oncology

A patient on nivolumab develops immune-related granulomatous hepatitis. Liver biopsy shows well-formed non-caseating epithelioid granulomas in the portal tracts. TB has been excluded. What is the differential and management?

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Correct answer: E — Immune-related granulomatous hepatitis — a variant of ICI hepatotoxicity that may be more steroid-resistant than conventional ICI hepatitis; management includes ICI hold, corticosteroids and possible ursodeoxycholic acid; sarcoidosis-like systemic granulomatous disease should be assessed

Granulomatous hepatitis is a recognised histological pattern of ICI liver toxicity, distinct from the more common lobular/portal hepatitis. It may be part of a systemic sarcoidosis-like granulomatous irAE (check for pulmonary/skin/lymph node involvement). Granulomatous ICI hepatitis may be more corticosteroid-resistant than typical ICI hepatitis. Management: ICI hold, prednisolone 1 mg/kg, ursodeoxycholic acid (adjunctive for cholestatic component). If steroid-refractory, mycophenolate or azathioprine may be needed. Infliximab remains contraindicated for liver irAEs.

Reference: ESMO 2024 irAE Management; De Martin et al Hepatology 2018