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Rossi S, Farina A, Malvaso A, Dinoto A, Fionda L, Cornacchini S, Florean I, Zuliani L, Garibaldi M, Lauletta A, Baccari F, Zenesini C, Rinaldi R, Mariotto S, Damato V, Diamanti L, Gastaldi M, Vogrig A, Marchioni E, Guarino M. Clinical Course of Neurologic Adverse Events Associated With Immune Checkpoint Inhibitors: Focus on Chronic Toxicities. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200314. [PMID: 39298719 DOI: 10.1212/nxi.0000000000200314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
BACKGROUND AND OBJECTIVES The clinical course and the risk of chronicity of neurologic immune-related adverse events (n-irAEs) associated with immune checkpoint inhibitors (ICIs) are not well documented. This study aimed to characterize the clinical course of n-irAEs and assess the prevalence of chronic events. METHODS This nationwide, multicenter, retrospective study included patients with n-irAEs identified at 7 Italian hospitals. The clinical course of n-irAEs was categorized into fulminant (if resulted in death within 12 weeks), monophasic (if resolved within 12 weeks), and chronic (if persisted beyond 12 weeks). Chronic n-irAEs were further subdivided into active (if there was indirect evidence of ongoing inflammation [i.e., required ongoing immunosuppression, relapsed on steroid tapering, or exhibited neurologic progression]) and inactive (if patients had neurologic sequelae without ongoing inflammation). Comparisons between groups and time-to-death analyses were performed. RESULTS Sixty-six patients were included (median age: 69 years [IQR 62-75]; 53 [80%] men). n-irAEs involved the peripheral nervous system in 48 patients (73%), the central nervous system in 14 (21%), and both in 4 (6%). Twelve patients (18%) had a fulminant course, with the risk being significantly higher in those with concurrent myocarditis (OR 5.4; 95% CI [1.02-28.31]). Among 54 patients with a nonfulminant course, 23 (43%) had a monophasic n-irAE and 31 (57%) had a chronic n-irAE, of which 16 of 31 (52%) were chronic active (due to ongoing immunosuppression [69%], relapses at corticosteroid tapering [19%], or neurologic disease progression [12%]) and 15 of 31 (48%) were chronic inactive. In patients with chronic inactive n-irAEs, neurologic sequelae included cerebellar ataxia (33%), neuromuscular weakness (27%), visual loss (13%), sensory disturbances (13%), focal neurologic signs (7%), and cognitive impairment (7%). Compared with patients with monophasic events, those with chronic n-irAEs had a higher rate of severe neurologic disability at the last evaluation (p < 0.01), shorter survival (p < 0.01), and higher overall mortality (p < 0.01), primarily due to cancer progression. DISCUSSION More than half of the patients with n-irAEs who survived the acute phase developed a chronic condition. Patients with chronic n-irAEs were at higher risk of death, mainly due to cancer progression. Future studies are needed to further characterize chronic n-irAEs and identify optimal long-term management strategies.
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Affiliation(s)
- Simone Rossi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Farina
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Malvaso
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Alessandro Dinoto
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Laura Fionda
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Sara Cornacchini
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Irene Florean
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Luigi Zuliani
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Matteo Garibaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Lauletta
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Flavia Baccari
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Corrado Zenesini
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Rita Rinaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Sara Mariotto
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Valentina Damato
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Luca Diamanti
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Matteo Gastaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Alberto Vogrig
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Enrico Marchioni
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Maria Guarino
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
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Pichon S, Aigrain P, Lacombe C, Lemarchant B, Ledoult E, Koether V, Leurs A, Zebian G, Launay D, Gachet B, Levy C. Immune checkpoint inhibitors-associated cranial nerves involvement: a systematic literature review on 136 patients. J Neurol 2024; 271:6514-6525. [PMID: 39225744 PMCID: PMC11446990 DOI: 10.1007/s00415-024-12660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 08/20/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE Describe the demographic data and clinical phenotype of cranial palsy induced by immune checkpoint inhibitors (CNP-ICI). METHODS A systematic literature review of the literature was performed in Pubmed, Web of Science, and Embase, including 68 articles and 136 patients (PROSPERO no. CRD42024517262). RESULTS Out of the 1205 articles screened, 68 articles were included after fulfilling the inclusion criteria, for a total of 136 patients. All articles were case reports and case series. In the cohort studied, 52% of patients were treated with anti PD-1/PDL-1 therapies, 14% with anti CTLA-4 therapies, and 34% with a combination of anti CTLA-4 and anti PD-1/PDL-1 therapies. The facial nerve was the most affected cranial nerve, involved in 38% of cases, followed by the optic nerve (35%), the cochleovestibular nerve (12%), and the abducens nerve (10%). The median time from the initial immune checkpoint inhibitor (ICI) injection to the onset CNP-ICI was 10 weeks (IQR 4-20). Magnetic resonance imaging demonstrated contrast enhancement or abnormal signal of the affected nerve in 43% of cases. Cerebrospinal fluid analysis indicated lymphocytic pleocytosis in 59% of cases. At the onset of immune-related adverse events, 89% of patients discontinued immunotherapy, and 92% received treatment for CNP-ICI. Treatment regimens included corticosteroids in 86% of cases, intravenous immunoglobulin in 21%, and plasma exchange in 5.1%. Among the whole population, 33% achieved recovery, 52% showed clinical improvement, 16% remained stable, and 3% experienced worsening of their condition. Rechallenge with immunotherapy was significantly associated with the emergence of new immune-related Adverse Events (irAEs). CONCLUSION ICI therapy may lead to cranial nerve involvement, particularly affecting the facial nerve, typically presenting around 10 weeks after treatment initiation. While corticosteroid therapy often resulted in patient improvement, rechallenging with ICIs were associated with new irAEs.
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Affiliation(s)
- Samuel Pichon
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France.
| | - Pauline Aigrain
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - Charlotte Lacombe
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - Bruno Lemarchant
- Département de Neurologie, CRC-SEP, Université de Lille, CHU Lille, 59000, Lille, France
| | - Emmanuel Ledoult
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
- U1286-INFINITE-Institute for Translational Research in Inflammation, INSERM, Université de Lille, CHU Lille, Lille, France
| | - Vincent Koether
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
| | - Amélie Leurs
- Département de Médecine Interne et Maladies Infectieuses, CH Dunkerque, 59240, Dunkerqu, France
| | - Ghadi Zebian
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - David Launay
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
- U1286-INFINITE-Institute for Translational Research in Inflammation, INSERM, Université de Lille, CHU Lille, Lille, France
| | - Benoit Gachet
- Service de Maladies Infectieuses, CH Gustave Dron, Université de Lille, 59200, Tourcoing, France
- ULR 2694 METRICS Evaluation des Technologies de Santé et des Pratiques Médicales, CH de Tourcoing, Université de Lille, 59000, Lille, France
| | - Clémentine Levy
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
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Gang X, Yan J, Li X, Shi S, Xu L, Liu R, Cai L, Li H, Zhao M. Immune checkpoint inhibitors rechallenge in non-small cell lung cancer: Current evidence and future directions. Cancer Lett 2024; 604:217241. [PMID: 39260670 DOI: 10.1016/j.canlet.2024.217241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 08/23/2024] [Accepted: 09/06/2024] [Indexed: 09/13/2024]
Abstract
Immunotherapy, remarkably immune checkpoint inhibitors (ICIs), has significantly altered the treatment landscape for non-small cell lung cancer (NSCLC). Despite their success, the discontinuation of ICIs therapy may occur due to factors such as prior treatment completion, disease progression during ICIs treatment, or immune-related adverse events (irAEs). As numerous studies highlight the dynamic nature of immune responses and the sustained benefits of ICIs, ICIs rechallenge has become an attractive and feasible option. However, the decision-making process for ICIs rechallenge in clinical settings is complicated by numerous uncertainties. This review systematically analyses existing clinical research evidence, classifying ICIs rechallenge into distinct clinical scenarios, exploring methods to overcome ICIs resistance in rechallenge instances, and identifying biomarkers to select patients likely to benefit from rechallenge. By integrating recent studies and new technologies, we offer crucial recommendations for future clinical trial design and provide a practical guideline to maximize the therapeutic benefits of immunotherapy for NSCLC patients.
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Affiliation(s)
- Xiaoyu Gang
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Jinshan Yan
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Xin Li
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Sha Shi
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Lu Xu
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Ruotong Liu
- Clinical Medicine, Shenyang Medical College, Shenyang, 110001, China
| | - Lutong Cai
- Psychological Medicine, Shenyang Medical College, Shenyang, 110001, China
| | - Heming Li
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, 110001, China; Guangdong Association of Clinical Trials (GACT)/Chinese Thoracic Oncology Group (CTONG) and Guangdong Provincial Key Lab of Translational Medicine in Lung Cancer, Guangzhou, 510000, China.
| | - Mingfang Zhao
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, 110001, China.
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O'Hare M, Guidon AC. Peripheral nervous system immune-related adverse events due to checkpoint inhibition. Nat Rev Neurol 2024; 20:509-525. [PMID: 39122934 DOI: 10.1038/s41582-024-01001-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/12/2024]
Abstract
Immune checkpoint inhibitors have revolutionized cancer therapy and are increasingly used to treat a wide range of oncological conditions, with dramatic benefits for many patients. Unfortunately, the resulting increase in T cell effector function often results in immune-related adverse events (irAEs), which can involve any organ system, including the central nervous system (CNS) and peripheral nervous system (PNS). Neurological irAEs involve the PNS in two-thirds of affected patients. Muscle involvement (immune-related myopathy) is the most common PNS irAE and can be associated with neuromuscular junction involvement. Immune-related peripheral neuropathy most commonly takes the form of polyradiculoneuropathy or cranial neuropathies. Immune-related myopathy (with or without neuromuscular junction involvement) often occurs along with immune-related myocarditis, and this overlap syndrome is associated with substantially increased mortality. This Review focuses on PNS adverse events associated with immune checkpoint inhibition. Underlying pathophysiological mechanisms are discussed, including antigen homology between self and tumour, epitope spreading and activation of pre-existing autoreactive T cells. An overview of current approaches to clinical management is provided, including cytokine-directed therapies that aim to decouple anticancer immunity from autoimmunity and emerging treatments for patients with severe (life-threatening) presentations.
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Affiliation(s)
- Meabh O'Hare
- Brigham and Women's Hospital, Division of Neuromuscular Medicine, Department of Neurology, Boston, MA, USA.
- Massachusetts General Hospital, Division of Neuromuscular Medicine, Department of Neurology, Boston, MA, USA.
| | - Amanda C Guidon
- Massachusetts General Hospital, Division of Neuromuscular Medicine, Department of Neurology, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Farina A, Villagrán-García M, Fourier A, Pinto AL, Chorfa F, Timestit N, Alberto T, Aupy J, Benaiteau M, Birzu C, Campetella L, Cotton F, Dalle S, Delaruelle CF, Dumez P, Germi R, Le Maréchal M, Maillet D, Marignier R, Pegat A, Psimaras D, Rafiq M, Picard G, Desestret V, Quadrio I, Honnorat J, Joubert B. Diagnostic and prognostic biomarkers in immune checkpoint inhibitor-related encephalitis: a retrospective cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 44:101011. [PMID: 39170102 PMCID: PMC11338149 DOI: 10.1016/j.lanepe.2024.101011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/06/2024] [Accepted: 07/11/2024] [Indexed: 08/23/2024]
Abstract
Background Immune checkpoint inhibitor-related encephalitis (ICI-encephalitis) is not well characterised and diagnostic and prognostic biomarkers are lacking. We aimed to comprehensively characterise ICI-encephalitis and identify diagnostic biomarkers and outcome predictors. Methods This retrospective observational study included all patients with ICI-encephalitis studied in the French Reference Centre on Paraneoplastic Neurological Syndromes (PNS) and Autoimmune Encephalitis (2015-2023). ICI encephalitis was considered definite in case of inflammatory findings at paraclinical tests and/or well-characterised neural antibodies. Predictors of immune-related adverse event (irAE) treatment response, defined as a Common Terminology Criteria for Adverse Events v5.0 grade < 3 at any time after therapeutic intervention, were assessed by logistic regression analysis, and predictors of mortality by Cox regression analysis. Neurofilament light chain (NfL) was measured by enzyme-linked immunosorbent assay. Findings Sixty-seven patients with definite encephalitis were identified (median age, 69 years; 66% male). A focal syndrome was observed in 43/67 patients (64%; limbic encephalitis, cerebellar ataxia, and/or brainstem encephalitis), while 24/67 (36%) had meningoencephalitis, a non-focal syndrome with altered mental status (22/24 patients, 92%) and pleocytosis (24/24 patients, 100%). Patients with focal encephalitis more frequently had abnormal brain MRI (26/42, 62% versus 8/24, 33%, p = 0.025), PNS-related antibodies (36/43, 84% versus 1/24, 4%, p < 0.001), and neuroendocrine cancers (22/43, 51% versus 1/24, 4%; p < 0.001) than patients with meningoencephalitis. Focal encephalitis patients had a lower rate of irAE treatment response (7/39, 18%) and higher mortality (27/43, 63%) compared to meningoencephalitis patients (12/22, 77% and 5/24, 21%, respectively, p < 0.001 each). PNS-related antibodies were associated with less irAE treatment response, independently of age, sex, and baseline severity (adjusted OR 0.05; 95%CI [0.01; 0.19]; p < 0.001) as well as higher mortality, independently of age and cancer type (adjusted HR 5.07; 95% CI [2.12; 12.12]; p < 0.001). Serum NfL discriminated patients with definite ICI-encephalitis (n = 27) from cancer-matched controls (n = 16; optimal cut-off >273.5 pg/mL, sensitivity 81%, specificity 88%, AUC 0.87, 95% CI [0.76; 0.98]) and irAE treatment responders (n = 10) from non-responders (n = 17, optimal cut-off >645 pg/mL, sensitivity 90%, specificity 65%; AUC 0.75, 95% CI [0.55; 0.94]). Interpretation ICI-encephalitis corresponds to a set of clinically-recognisable syndromes. Patients with focal encephalitis, PNS-related antibodies, and/or higher serum NfL have low irAE treatment response rates. Research is needed on the underlying immunopathogenesis to foster therapeutic innovations. Funding Agence Nationale de la Recherche.
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Affiliation(s)
- Antonio Farina
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Macarena Villagrán-García
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Anthony Fourier
- Lyon Neuroscience Research Center (CRNL), Université de Lyon, CNRS, INSERM, Lyon, France
| | - Anne-Laurie Pinto
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Fatima Chorfa
- Service de Biostatistique et Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Noémie Timestit
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Tifanie Alberto
- Department of Neurology, CRC SEP, Centre Hospitalier of Lille, Lille, France
| | - Jérôme Aupy
- Department of Clinical Neurosciences, Centre Hospitalier of Bordeaux, Bordeaux, France
- CNRS, IMN, UMR 5293, University of Bordeaux, Bordeaux, France
| | - Marie Benaiteau
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Cristina Birzu
- AP-HP, Hospital Group Pitié-Salpêtrière, Neuro-oncology Department Paris, France
- Inserm U1127, CNRS, Paris Brain Institute, Institut du Cerveau (ICM), Paris, France
| | - Lucia Campetella
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - François Cotton
- Radiology Department, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Stéphane Dalle
- Deparment of Dermatology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
| | - Clara Fontaine Delaruelle
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
- Department of Pneumology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Pauline Dumez
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Rafaele Germi
- Virology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Marion Le Maréchal
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Denis Maillet
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
- Department of Medical Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hospices Civils de Lyon, Lyon, France
| | - Antoine Pegat
- Service ENMG et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, INMG, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
| | - Dimitri Psimaras
- AP-HP, Hospital Group Pitié-Salpêtrière, Neuro-oncology Department Paris, France
- Inserm U1127, CNRS, Paris Brain Institute, Institut du Cerveau (ICM), Paris, France
| | - Marie Rafiq
- Department of Cognitive Neurology, Epilepsy and Movement Disorders, Toulouse Purpan University Hospital Center, Toulouse, France
| | - Géraldine Picard
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Virginie Desestret
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Isabelle Quadrio
- Lyon Neuroscience Research Center (CRNL), Université de Lyon, CNRS, INSERM, Lyon, France
| | - Jérôme Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
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Ruiz-Esteves KN, Shank KR, Deutsch AJ, Gunturi A, Chamorro-Pareja N, Colling CA, Zubiri L, Perlman K, Ouyang T, Villani AC, Florez JC, Gusev A, Reynolds KL, Miller KK, Udler MS, Sise ME, Rengarajan M. Identification of Immune Checkpoint Inhibitor-Induced Diabetes. JAMA Oncol 2024:2822927. [PMID: 39207773 PMCID: PMC11362970 DOI: 10.1001/jamaoncol.2024.3104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/15/2024] [Indexed: 09/04/2024]
Abstract
Importance Immune checkpoint inhibitors (ICIs) have revolutionized cancer care; however, accompanying immune-related adverse events (irAEs) confer substantial morbidity and occasional mortality. Life-threatening irAEs may require permanent cessation of ICI, even in patients with positive tumor response. Therefore, it is imperative to comprehensively define the spectrum of irAEs to aid individualized decision-making around the initiation of ICI therapy. Objective To define incidence, risk factors, and clinical spectrum of an irreversible and life-threatening irAE: ICI-induced diabetes. Design, Setting, and Participants This cohort study, conducted at an academic integrated health care system examined 14 328 adult patients treated with ICIs, including 64 patients who developed ICI-induced diabetes, from July 2010 to January 2022. The data were analyzed from 2022 to 2023. Cases of ICI-induced diabetes were manually confirmed; detailed clinical phenotyping was performed at diagnosis and 1-year follow-up. For 862 patients, genotyping data were available, and polygenic risk for type 1 diabetes was determined. Main Outcomes and Measures For ICI-induced diabetes cases and controls, demographic characteristics, comorbidities, tumor category, and ICI category were compared. Among ICI-induced diabetes cases, markers of glycemic physiology were examined at diagnosis and 1-year follow-up. For patients with available genotyping, a published type 1 diabetes polygenic score (T1D GRS2) was calculated. Results Of 14 328 participants, 6571 (45.9%) were women, and the median (range) age was 66 (8-106) years. The prevalence of ICI-induced diabetes among ICI-treated patients was 0.45% (64 of 14 328), with an incidence of 124.8 per 100 000 person-years. Preexisting type 2 diabetes (odds ratio [OR], 5.91; 95% CI, 3.34-10.45) and treatment with combination ICI (OR, 2.57; 95% CI, 1.44-4.59) were significant clinical risk factors of ICI-induced diabetes. T1D GRS2 was associated with ICI-induced diabetes risk, with an OR of 4.4 (95% CI, 1.8-10.5) for patients in the top decile of T1D GRS2, demonstrating a genetic association between spontaneous autoimmunity and irAEs. Patients with ICI-induced diabetes were in 3 distinct phenotypic categories based on autoantibodies and residual pancreatic function, with varying severity of initial presentation. Conclusions and Relevance The results of this analysis of 14 328 ICI-treated patients followed up from ICI initiation determined the incidence, risk factors and clinical spectrum of ICI-induced diabetes. Widespread implementation of this approach across organ-specific irAEs may enhance diagnosis and management of these conditions, and this becomes especially pertinent as ICI treatment rapidly expands to treat a wide spectrum of cancers and is used at earlier stages of treatment.
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Affiliation(s)
- Karina N. Ruiz-Esteves
- Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School, Boston
| | - Kaitlyn R. Shank
- Department of Medicine, Massachusetts General Hospital and Department of Medicine, Brigham and Women’s Hospital, Boston
| | - Aaron J. Deutsch
- Department of Medicine and Center for Genomic Medicine, Massachusetts General Hospital, Programs in Metabolism and Medical and Population Genetics, Broad Institute, Cambridge
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Alekhya Gunturi
- Department of Medicine, Massachusetts General Hospital and Boston University School of Medicine, Boston
| | - Natalia Chamorro-Pareja
- Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School, Boston
| | - Caitlin A. Colling
- Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School, Boston
| | - Leyre Zubiri
- Department of Medicine, Massachusetts General Hospital, Boston, MA and Harvard Medical School, Boston
| | | | - Tianqi Ouyang
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Alexandra-Chloé Villani
- Center for Cancer Research, Department of Medicine, Massachusetts General Hospital, Boston
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jose C. Florez
- Department of Medicine and Center for Genomic Medicine, Massachusetts General Hospital, Programs in Metabolism and Medical and Population Genetics, Broad Institute, Cambridge
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Alexander Gusev
- Division of Population Sciences, Dana-Farber Cancer Institute and Harvard Medical School, Broad Institute, Cambridge, Massachusetts
- Division of Genetics, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Kerry L. Reynolds
- Department of Medicine, Mass General Cancer Center, Massachusetts General Hospital, Boston
| | - Karen K. Miller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Miriam S. Udler
- Department of Medicine and Center for Genomic Medicine, Massachusetts General Hospital, Programs in Metabolism and Medical and Population Genetics, Broad Institute, Cambridge
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Meghan E. Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Michelle Rengarajan
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Broad Institute of Massachusetts Institute of Technology and Harvard University, Boston
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7
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Dentoni M, Florean I, Farina A, Joubert B, Do LD, Honnorat J, Damato V, Fabris M, Gigli GL, Valente M, Vogrig A. Immune Checkpoint Inhibitor-Related Cerebellar Toxicity: Clinical Features and Comparison with Paraneoplastic Cerebellar Ataxia. CEREBELLUM (LONDON, ENGLAND) 2024:10.1007/s12311-024-01727-5. [PMID: 39153058 DOI: 10.1007/s12311-024-01727-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 08/19/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy, and the association with immune-related adverse events (irAEs) is well-established. However, cerebellar irAEs are poorly defined and their relationship with paraneoplastic disorders remains unclear. Our aim was (i) to characterize cerebellar irAE; (ii) to compare it with paraneoplastic cerebellar ataxia (PCA). We performed a multicenter, retrospective, cohort study of patients developing new-onset, immune-mediated, isolated/predominant cerebellar dysfunction after ICI administration. In addition, a systematic review following PRISMA guidelines was performed. Cerebellar irAE cases were compared with a consecutive cohort of patients with PCA. Overall, 35 patients were included, of whom 12 were original cases (males: 25/35 (71%), median age: 65 [range: 20-82]). The most frequent tumor was non-small cell lung cancer (12/35, 34%). Anti-PD1 were adopted in 19/35 (54%). Symptoms developed at a median of 11 weeks after ICI onset. Neuronal antibodies were detected in 15/31 patients tested (48%). Cerebrospinal fluid was inflammatory in 25/30 (83%). Magnetic resonance imaging showed cerebellar hyperintensities in 8/35 (23%). Immunotherapy was applied in 33/35 cases (94%), and most patients improved with residual disability (16/35, 46%). When compared with a series of PCA (n = 15), the cerebellar irAE group was significantly more associated with male sex, lung cancer (rather than gynecological/breast cancers), isolated ataxia, and a better outcome. We provide a detailed characterization of cerebellar irAE. Compared to PCA, differences exist in terms of tumor association, clinical features, and outcome. Clinical presentation-antibody-tumor triad in the ICI group only partially reflects the associations described in paraneoplastic disorders.
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Affiliation(s)
- Marta Dentoni
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Irene Florean
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Antonio Farina
- French Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Lyon, France
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Lyon, France
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Le-Duy Do
- French Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Lyon, France
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Honnorat
- French Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Lyon, France
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Valentina Damato
- Department of Neurosciences, Drugs and Child Health, University of Florence, Firenze, Italy
| | - Martina Fabris
- Laboratory of Immunopathology, Institute of Clinical Pathology, Department of Laboratory Medicine, University Hospital of Udine, Udine, Italy
- Institute of Clinical Pathology, Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Alberto Vogrig
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy.
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy.
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8
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Clardy SL, Smith TL. Therapeutic Approach to Autoimmune Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1226-1258. [PMID: 39088294 DOI: 10.1212/con.0000000000001463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE Autoimmune neurologic disorders encompass a broad category of diseases characterized by immune system attack of the central, peripheral, or autonomic nervous systems. This article provides information on both acute and maintenance immunotherapy used to treat autoimmune neurologic disorders as well as a review of symptomatic management and special considerations when caring for patients with these diseases. LATEST DEVELOPMENTS Over the past 20 years, more than 50 antibodies have been identified and associated with autoimmune neurologic disorders. Although advances in diagnostic testing have allowed for more rapid diagnosis, the therapeutic approach to these disorders has largely continued to rely on expert opinion, case series, and case reports. With US Food and Drug Administration (FDA) approval of biologic agents to treat neuromyelitis optica spectrum disorder (NMOSD) and myasthenia gravis as well as ongoing clinical trials for the treatment of autoimmune encephalitis, the landscape of immunotherapy options continues to expand. Consideration of the unique pathogenesis of individual autoimmune neurologic disorders as well as the mechanism of action of the diverse range of treatment options can help guide treatment decisions today while evidence from clinical trials informs new therapeutics in the future. ESSENTIAL POINTS Recognizing patients who have a clinical history and examination findings concerning for autoimmune neurologic disorders and conducting a thorough and directed imaging and laboratory evaluation aimed at ruling out mimics, identifying specific autoimmune syndromes, and screening for factors that may have an impact on immunotherapy choices early in the clinical course are essential to providing optimal care for these patients. Providers must consider immunotherapy, symptomatic treatment, and a multidisciplinary approach that addresses each patient's unique needs when treating patients with autoimmune neurologic disorders.
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9
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Malvaso A, Giglio P, Diamanti L, Gastaldi M, Vegezzi E, Pace A, Bini P, Marchioni E. Unravelling the Acute, Chronic and Steroid-Refractory Management of High-Grade Neurological Immune-Related Adverse Events: A Call to Action. Brain Sci 2024; 14:764. [PMID: 39199458 PMCID: PMC11352216 DOI: 10.3390/brainsci14080764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 07/17/2024] [Accepted: 07/25/2024] [Indexed: 09/01/2024] Open
Abstract
Rare side effects of immune-checkpoint inhibitors (ICIs) are known as neurological immune-related adverse events (n-irAEs). Typically, n-irAEs affect the peripheral nervous system, primarily presenting as myositis, polyradiculoneuropathy, or cranial neuropathy. Less commonly, they impact the central nervous system, resulting in encephalitis, meningitis, or myelitis. High-grade n-irAEs managing and recognizing remains challenging, considering the risk of mortality and long-term disability. To date, strong scientific data are lacking to support the management of high-grade clinical forms. We performed a systematic literature search, selecting all articles describing high-grade steroid-resistance n-irAEs. and we reported them in a practical review. Specifically, current recommendations advise stopping ICI use and beginning corticosteroid treatment. Our findings highlighted that in steroid-resistant n-irAEs, it should be recommended to quickly escalate to plasma exchange (PLEX) and/or intravenously immunoglobulins (IVIg), usually in association with other immunosuppressants. Furthermore, newer evidence supports the use of drugs that may specifically block inflammation without reducing the anti-tumour effect of ICIs. In this practical review, we provide new evidence regarding the therapeutic approach of high-grade n-irAEs, particularly in steroid-resistant cases. We would also stress the importance of informing the scientific community of the discrepancy between current guidelines and clinical evidence in these rare forms of pathology.
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Affiliation(s)
- Antonio Malvaso
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.M.); (P.G.)
- Neuroimmunology Research Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy;
| | - Pierpaolo Giglio
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.M.); (P.G.)
| | - Luca Diamanti
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Matteo Gastaldi
- Neuroimmunology Research Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy;
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Elisa Vegezzi
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Andrea Pace
- IRCCS Regina Elena, Istituto Nazionale Tumori, 00144 Rome, Italy;
| | - Paola Bini
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Enrico Marchioni
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
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10
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Afshari AR, Sanati M, Ahmadi SS, Kesharwani P, Sahebkar A. Harnessing the capacity of phytochemicals to enhance immune checkpoint inhibitor therapy of cancers: A focus on brain malignancies. Cancer Lett 2024; 593:216955. [PMID: 38750720 DOI: 10.1016/j.canlet.2024.216955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/23/2024]
Abstract
Brain cancers, particularly glioblastoma multiforme (GBM), are challenging health issues with frequent unmet aspects. Today, discovering safe and effective therapeutic modalities for brain tumors is among the top research interests. Immunotherapy is an emerging area of investigation in cancer treatment. Since immune checkpoints play fundamental roles in repressing anti-cancer immunity, diverse immune checkpoint inhibitors (ICIs) have been developed, and some monoclonal antibodies have been approved clinically for particular cancers; nevertheless, there are significant concerns regarding their efficacy and safety in brain tumors. Among the various tools to modify the immune checkpoints, phytochemicals show good effectiveness and excellent safety, making them suitable candidates for developing better ICIs. Phytochemicals regulate multiple immunological checkpoint-related signaling pathways in cancer biology; however, their efficacy for clinical cancer immunotherapy remains to be established. Here, we discussed the involvement of immune checkpoints in cancer pathology and summarized recent advancements in applying phytochemicals in modulating immune checkpoints in brain tumors to highlight the state-of-the-art and give constructive prospects for future research.
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Affiliation(s)
- Amir R Afshari
- Natural Products and Medicinal Plants Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran; Department of Physiology and Pharmacology, Faculty of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Mehdi Sanati
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Birjand University of Medical Sciences, Birjand, Iran; Experimental and Animal Study Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Seyed Sajad Ahmadi
- Department of Ophthalmology, Khatam-Ol-Anbia Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Prashant Kesharwani
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India.
| | - Amirhossein Sahebkar
- Center for Global Health Research, Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India; Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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11
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Stavropoulou De Lorenzo S, Andravizou A, Alexopoulos H, Michailidou I, Bokas A, Kesidou E, Boziki MK, Parissis D, Bakirtzis C, Grigoriadis N. Neurological Immune-Related Adverse Events Induced by Immune Checkpoint Inhibitors. Biomedicines 2024; 12:1319. [PMID: 38927526 PMCID: PMC11202292 DOI: 10.3390/biomedicines12061319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
The use of immune checkpoint inhibitors (ICIs) for the treatment of various advanced and aggressive types of malignancy has significantly increased both survival and long-term remission rates. ICIs block crucial inhibitory pathways of the immune system, in order to trigger an aggravated immune response against the tumor. However, this enhanced immune activation leads to the development of numerous immune-related adverse events (irAEs), which may affect any system. Although severe neurological irAEs are relatively rare, they carry a high disability burden, and they can be potentially life-threatening. Therefore, clinicians must be alert and act promptly when individuals receiving ICIs present with new-onset neurological symptoms. In this narrative review, we have collected all the currently available data regarding the epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of post-ICI neurological irAEs. This review aims to raise physicians' awareness, enrich their knowledge regarding disease pathogenesis, and guide them through the diagnosis and management of post-ICI neurological irAEs.
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Affiliation(s)
- Sotiria Stavropoulou De Lorenzo
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Athina Andravizou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Harry Alexopoulos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, University Campus, 15784 Athens, Greece;
| | - Iliana Michailidou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Alexandros Bokas
- Department of Medical Oncology, Theageneio Cancer Hospital, 54639 Thessaloniki, Greece;
| | - Evangelia Kesidou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Marina-Kleopatra Boziki
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Dimitrios Parissis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Christos Bakirtzis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Nikolaos Grigoriadis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
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12
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Farina A, Villagrán-García M, Vogrig A, Joubert B. Central nervous system adverse events of immune checkpoint inhibitors. Curr Opin Neurol 2024; 37:345-352. [PMID: 38483130 DOI: 10.1097/wco.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICI) may trigger immune-related adverse events which rarely affect the central nervous system (CNS-irAEs). Over the past few years, cumulative data have led to the characterization of well defined syndromes with distinct cancer and antibody associations as well as different outcomes. RECENT FINDINGS The most frequent CNS-irAE is encephalitis, which includes three main groups: meningoencephalitis, a nonfocal syndrome usually responsive to corticosteroids; limbic encephalitis, associated with high-risk paraneoplastic neurological syndromes (PNS) antibodies (e.g. anti-Hu, anti-Ma2) and neuroendocrine cancers, characterized by poor treatment response and outcomes; and cerebellar ataxia, with variable outcomes (worse when high-risk PNS antibodies are detected). Additionally, a diffuse encephalopathy without inflammatory findings, with poor response to corticosteroids and high mortality has been described. The spectrum of CNS-irAEs also includes meningitis, myelitis, and rarer presentations. A subset of CNS-irAEs (i.e. limbic encephalitis and/or rapidly progressive cerebellar ataxia) is undistinguishable from ICI-naïve PNS. SUMMARY The clinical and outcomes diversity of CNS-irAEs suggests different pathogenic mechanisms, which need to be understood to establish more effective and specific treatment modalities. It is crucial to identify biomarkers able to predict which patients will experience severe CNS-irAEs, to anticipate their diagnosis, and to predict long-term outcomes.
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Affiliation(s)
- Antonio Farina
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Macarena Villagrán-García
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- Department of Medicine (DMED), University of Udine
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Bastien Joubert
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
- Department of Neurology, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
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13
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Maciel CB, Busl KM. Neuro-oncologic Emergencies. Continuum (Minneap Minn) 2024; 30:845-877. [PMID: 38830073 DOI: 10.1212/con.0000000000001435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Neuro-oncologic emergencies have become more frequent as cancer remains one of the leading causes of death in the United States, second only to heart disease. This article highlights key aspects of epidemiology, diagnosis, and management of acute neurologic complications in primary central nervous system malignancies and systemic cancer, following three thematic classifications: (1) complications that are anatomically or intrinsically tumor-related, (2) complications that are tumor-mediated, and (3) complications that are treatment-related. LATEST DEVELOPMENTS The main driver of mortality in patients with brain metastasis is systemic disease progression; however, intracranial hypertension, treatment-resistant seizures, and overall decline due to increased intracranial burden of disease are the main factors underlying neurologic-related deaths. Advances in the understanding of tumor-specific characteristics can better inform risk stratification of neurologic complications. Following standardized grading and management algorithms for neurotoxic syndromes related to newer immunologic therapies is paramount to achieving favorable outcomes. ESSENTIAL POINTS Neuro-oncologic emergencies span the boundaries of subspecialties in neurology and require a broad understanding of neuroimmunology, neuronal hyperexcitability, CSF flow dynamics, intracranial compliance, and neuroanatomy.
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14
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Idogun PO, Hafez-Khayyata S, Ezekwudo D. Immune Checkpoint Inhibitor-Induced Guillain Barre Syndrome: A Single-Institution Case Report and Narrative Review. Cureus 2024; 16:e61489. [PMID: 38952584 PMCID: PMC11216129 DOI: 10.7759/cureus.61489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/03/2024] Open
Abstract
Guillain-Barré syndrome (GBS) resulting from the use of immune checkpoint inhibitors (ICIs) is relatively uncommon but has been reported. Herein, we discuss a case of a 67-year-old patient who received neoadjuvant ICI for treatment of non-small cell lung cancer and then presented with lower extremity weakness and areflexia, progressing to respiratory muscle and upper extremity weakness. Given the increasing use of ICI in cancer management, awareness of neurological autoimmune side effects is essential. ICI-mediated GBS can be severe and fatal if not diagnosed promptly. We discuss a case of ICI-induced GBS and review literature on current management approaches.
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Affiliation(s)
- Precious O Idogun
- Hematology and Medical Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| | - Said Hafez-Khayyata
- Pathology, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| | - Daniel Ezekwudo
- Hematology and Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, USA
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15
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Ma C, Liu D, Wang B, Yang Y, Zhu R. Advancements and prospects of novel biologicals for myasthenia gravis: toward personalized treatment based on autoantibody specificities. Front Pharmacol 2024; 15:1370411. [PMID: 38881870 PMCID: PMC11177092 DOI: 10.3389/fphar.2024.1370411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/06/2024] [Indexed: 06/18/2024] Open
Abstract
Myasthenia gravis (MG) is an antibody-mediated autoimmune disease with a prevalence of 150-250 cases per million individuals. Autoantibodies include long-lived antibodies against the acetylcholine receptor (AChR), mainly of the IgG1 subclass, and IgG4, produced almost exclusively by short-lived plasmablasts, which are prevalent in muscle-specific tyrosine kinase (MuSK) myasthenia gravis. Numerous investigations have demonstrated that MG patients receiving conventional medication today still do not possess satisfactory symptom control, indicating a substantial disease burden. Subsequently, based on the type of the autoantibody and the pathogenesis, we synthesized the published material to date and reached a conclusion regarding the literature related to personalized targeted therapy for MG. Novel agents for AChR MG have shown their efficacy in clinical research, such as complement inhibitors, FcRn receptor antagonists, and B-cell activating factor (BAFF) inhibitors. Rituximab, a representative drug of anti-CD20 therapy, has demonstrated benefits in treatment of MuSK MG patients. Due to the existence of low-affinity antibodies or unidentified antibodies that are inaccessible by existing methods, the treatment for seronegative MG remains complicated; thus, special testing and therapy considerations are necessary. It may be advantageous to initiate the application of novel biologicals at an early stage of the disease. Currently, therapies can also be combined and individualized according to different types of antibodies. With such a wide range of drugs, how to tailor treatment strategies to patients with various conditions and find the most suitable solution for each MG profile are our necessary and urgent aims.
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Affiliation(s)
- Chi Ma
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Dan Liu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Benqiao Wang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yingying Yang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ruixia Zhu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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16
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Xue G, Li X, Kalim M, Fang J, Jiang Z, Zheng N, Wang Z, Li X, Abdelrahim M, He Z, Nikiforov M, Jin G, Lu Y. Clinical drug screening reveals clofazimine potentiates the efficacy while reducing the toxicity of anti-PD-1 and CTLA-4 immunotherapy. Cancer Cell 2024; 42:780-796.e6. [PMID: 38518774 DOI: 10.1016/j.ccell.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 01/17/2024] [Accepted: 03/01/2024] [Indexed: 03/24/2024]
Abstract
Emerging as the most potent and durable combinational immunotherapy, dual anti-PD-1 and CTLA-4 immune checkpoint blockade (ICB) therapy notoriously increases grade 3-5 immune-related adverse events (irAEs) in patients. Accordingly, attempts to improve the antitumor potency of anti-PD-1+CTLA-4 ICB by including additional therapeutics have been largely discouraged due to concerns of further increasing fatal toxicity. Here, we screened ∼3,000 Food and Drug Administration (FDA)-approved drugs and identified clofazimine as a potential third agent to optimize anti-PD-1+CTLA-4 ICB. Remarkably, clofazimine outperforms ICB dose reduction or steroid treatment in reversing lethality of irAEs, but unlike the detrimental effect of steroids on antitumor efficacy, clofazimine potentiates curative responses in anti-PD-1+CTLA-4 ICB. Mechanistically, clofazimine promotes E2F1 activation in CD8+ T cells to overcome resistance and counteracts pathogenic Th17 cells to abolish irAEs. Collectively, clofazimine potentiates the antitumor efficacy of anti-PD-1+CTLA-4 ICB, curbs intractable irAEs, and may fill a desperate clinical need to improve patient survival.
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Affiliation(s)
- Gang Xue
- Comprehensive Cancer Center, Wake Forest Baptist Health, Winston-Salem, NC 27157, USA.
| | - Xin Li
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Muhammad Kalim
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Jing Fang
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Zhiwu Jiang
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Ningbo Zheng
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Ziyu Wang
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Xiaoyin Li
- Department of Mathematics and Statistics, St. Cloud State University, St Cloud, MN 56301, USA
| | - Maen Abdelrahim
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Zhiheng He
- Department of Molecular Microbiology and Immunology, University of Southern California, Los Angeles, CA 90033, USA.
| | | | - Guangxu Jin
- Comprehensive Cancer Center, Wake Forest Baptist Health, Winston-Salem, NC 27157, USA.
| | - Yong Lu
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA.
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Aboseif A, Vorasoot N, Pinto MV, Guo Y, Hasan S, Zekeridou A, Chen JJ, Dubey D. Immune Checkpoint Inhibitor-Associated Kelch-Like Protein-11 IgG Brainstem Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200218. [PMID: 38484218 DOI: 10.1212/nxi.0000000000200218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/19/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES Kelch-like protein-11 (KLHL11)-IgG is associated with rhombencephalitis and seminoma. It has not previously been described as a neurologic immune checkpoint inhibitor (ICI)-related adverse event (nirAE) or in association with esophageal adenocarcinoma. METHODS We describe a 61-year-old man with metastatic esophageal adenocarcinoma treated with folinic acid, fluorouracil, oxaliplatin (FOLFOX), and nivolumab, who subsequently developed diplopia, vertigo, and progressive gait ataxia after 8 weeks of treatment. RESULTS Owing to a concern for ICI-associated myasthenia gravis, nivolumab was held and he was treated with prednisone and pyridostigmine. EMG showed no neuromuscular junction dysfunction, and acetylcholine-receptor antibodies were negative. Brain MRI was unrevealing. Murine brain tissue immunofluorescence assay revealed KLHL11-IgG in both serum and CSF, confirmed by cell-based assay. Tumor histopathology demonstrated poorly differentiated, highly proliferative adenocarcinoma with increased mitotic figures and cytoplasmic KLHL11 immunoreactivity. He was initiated on 6 months of cyclophosphamide in addition to FOLFOX for post-ICI-associated KLHL11-IgG rhombencephalitis. DISCUSSION We report KLHL11-IgG rhombencephalitis associated with poorly differentiated esophageal cancer as a novel nirAE. Tumor staining revealed KLHL11 immunoreactivity, supporting a cancer-antigen-driven ICI-associated paraneoplastic syndrome. Recognition of novel nirAEs can expedite treatment and potentially prevent progressive neurologic disability.
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Affiliation(s)
- Albert Aboseif
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Nisa Vorasoot
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Marcus V Pinto
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Yong Guo
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Shemonti Hasan
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Anastasia Zekeridou
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - John J Chen
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Divyanshu Dubey
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
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18
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Zammit F, Seront E. Neurological Adverse Events Related to Immune Checkpoint Inhibitors: A Practical Review. Pharmaceuticals (Basel) 2024; 17:501. [PMID: 38675461 PMCID: PMC11053462 DOI: 10.3390/ph17040501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The increasing use of immune checkpoint inhibitors (ICI) in cancer therapy has brought attention to their associated neurotoxicities, termed neurological immune-related adverse events (n-irAEs). Despite their relatively rare incidence, n-irAEs pose a significant risk, potentially leading to severe, long-lasting disabilities or even fatal outcomes. This narrative review aims to provide a comprehensive overview of n-irAEs, focusing on their recognition and management. The review addresses a spectrum of n-irAEs, encompassing myositis, myasthenia gravis, various neuropathies, and central nervous system complications, such as encephalitis, meningitis, and demyelinating diseases. The key features of n-irAEs are emphasized in this review, including their early onset after initiation of ICIs, potential association with non-neurological irAEs and/or concurrent oncological response, the significance of ruling out other etiologies, and the expected improvement upon discontinuation of ICIs and/or immunosuppression. Furthermore, this review delves into considerations for ICI re-challenge and the intricate nature of n-irAEs within the context of pre-existing autoimmune and paraneoplastic syndromes. It underscores the importance of a multidisciplinary approach to diagnosis and treatment, highlighting the pivotal role of severity grading in guiding treatment decisions.
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Affiliation(s)
| | - Emmanuel Seront
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
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19
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Casagrande S, Sopetto GB, Bertalot G, Bortolotti R, Racanelli V, Caffo O, Giometto B, Berti A, Veccia A. Immune-Related Adverse Events Due to Cancer Immunotherapy: Immune Mechanisms and Clinical Manifestations. Cancers (Basel) 2024; 16:1440. [PMID: 38611115 PMCID: PMC11011060 DOI: 10.3390/cancers16071440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
The landscape of cancer treatment has undergone a significant transformation with the introduction of Immune Checkpoint Inhibitors (ICIs). Patients undergoing these treatments often report prolonged clinical and radiological responses, albeit with a potential risk of developing immune-related adverse events (irAEs). Here, we reviewed and discussed the mechanisms of action of ICIs and their pivotal role in regulating the immune system to enhance the anti-tumor immune response. We scrutinized the intricate pathogenic mechanisms responsible for irAEs, arising from the evasion of self-tolerance checkpoints due to drug-induced immune modulation. We also summarized the main clinical manifestations due to irAEs categorized by organ types, detailing their incidence and associated risk factors. The occurrence of irAEs is more frequent when ICIs are combined; with neurological, cardiovascular, hematological, and rheumatic irAEs more commonly linked to PD1/PD-L1 inhibitors and cutaneous and gastrointestinal irAEs more prevalent with CTLA4 inhibitors. Due to the often-nonspecific signs and symptoms, the diagnosis of irAEs (especially for those rare ones) can be challenging. The differential with primary autoimmune disorders becomes sometimes intricate, given the clinical and pathophysiological similarities. In conclusion, considering the escalating use of ICIs, this area of research necessitates additional clinical studies and practical insights, especially the development of biomarkers for predicting immune toxicities. In addition, there is a need for heightened education for both clinicians and patients to enhance understanding and awareness.
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Affiliation(s)
- Silvia Casagrande
- Unit of Neurology, Rovereto Hospital, Azienda Provinciale per i Servizi Sanitari-APSS, 38122 Trento, Italy; (S.C.); (B.G.)
| | - Giulia Boscato Sopetto
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38122 Trento, Italy; (G.B.S.); (G.B.); (V.R.)
| | - Giovanni Bertalot
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38122 Trento, Italy; (G.B.S.); (G.B.); (V.R.)
- Center for Medical Sciences (CISMed), University of Trento, 38122 Trento, Italy
- Multizonal Unit of Pathology, APSS, 38122 Trento, Italy
| | - Roberto Bortolotti
- Unit of Rheumatology, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy;
| | - Vito Racanelli
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38122 Trento, Italy; (G.B.S.); (G.B.); (V.R.)
- Center for Medical Sciences (CISMed), University of Trento, 38122 Trento, Italy
- Unit of Internal Medicine, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy
| | - Orazio Caffo
- Unit of Oncology, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy; (O.C.); (A.V.)
| | - Bruno Giometto
- Unit of Neurology, Rovereto Hospital, Azienda Provinciale per i Servizi Sanitari-APSS, 38122 Trento, Italy; (S.C.); (B.G.)
- Center for Medical Sciences (CISMed), University of Trento, 38122 Trento, Italy
- Department of Psychology and Cognitive Sciences (DIPSCO), University of Trento, 38122 Trento, Italy
| | - Alvise Berti
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38122 Trento, Italy; (G.B.S.); (G.B.); (V.R.)
- Center for Medical Sciences (CISMed), University of Trento, 38122 Trento, Italy
- Unit of Rheumatology, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy;
| | - Antonello Veccia
- Unit of Oncology, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy; (O.C.); (A.V.)
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20
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Müller-Jensen L, Knauss S, Ginesta Roque L, Schinke C, Maierhof SK, Bartels F, Finke C, Rentzsch K, Ulrich C, Mohr R, Stenzel W, Endres M, Boehmerle W, Huehnchen P. Dataset for: Autoantibody profiles in patients with immune checkpoint inhibitor-induced neurological immune-related adverse events. Data Brief 2024; 53:110062. [PMID: 38317734 PMCID: PMC10838681 DOI: 10.1016/j.dib.2024.110062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 01/09/2024] [Indexed: 02/07/2024] Open
Abstract
The rise of cancer immunotherapy has been a milestone in clinical oncology. Above all, immune checkpoint inhibitor treatment (ICI) with monoclonal antibodies targeting programmed cell death protein 1 (PD-1), programmed cell death-ligand 1 (PD-L1), and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) has improved survival rates for an increasing number of malignancies. However, despite the clinical benefits, ICI-related autoimmunity has become a significant cause of non-relapse-related morbidity and mortality. Neurological immune-related adverse events (irAE-n) are particularly severe toxicities with a high risk for chronic illness, long-term steroid dependency, and early ICI treatment termination. While the clinical characteristics of irAE-n are well described, little is known about underlying immune mechanisms and potential biomarkers. Recently, high frequencies of neuronal autoantibodies in patients with irAE-n have been reported, however, their clinical relevance is unclear. Here, we present a dataset on neuronal autoantibody profiles in ICI-treated cancer patients with and without irAE-n, which was generated to investigate the potential role of neuronal autoantibodies in ICI-induced autoimmunity. Between September 2017 and January 2022 serum samples of 29 cancer patients with irAE-n post-ICI treatment) and 44 cancer control patients without high-grade immune-related adverse events (irAEs, n = 44 pre- and post-ICI treatment) were collected and tested for a large panel of brain-reactive and neuromuscular autoantibodies using indirect immunofluorescence and immunoblot assays. Prevalence of autoantibodies was compared between the groups and correlated with clinical characteristics such as outcome and irAE-n manifestation. These data represent the first systematic comparison of neuronal autoantibody profiles between ICI-treated cancer patients with and without irAE-n, providing valuable information for both researchers and clinicians. In the future, this dataset may be valuable for meta-analyses on the prevalence of neuronal autoantibodies in cancer patients.
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Affiliation(s)
- Leonie Müller-Jensen
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité, Universitätsmedizin Berlin, BIH Academy, (Junior) Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Samuel Knauss
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité, Universitätsmedizin Berlin, BIH Academy, (Junior) Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Lorena Ginesta Roque
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
| | - Christian Schinke
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité, Universitätsmedizin Berlin, BIH Academy, (Junior) Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Smilla K. Maierhof
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Einstein Center for Neurosciences Berlin (ECN) at Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Frederik Bartels
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité, Universitätsmedizin Berlin, BIH Academy, (Junior) Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Carsten Finke
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Humboldt-Universität zu Berlin, Berlin School of Mind and Brain, Berlin, Germany
| | - Kristin Rentzsch
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Groß Grönau, Germany
| | - Claas Ulrich
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venerology and Allergology, Charitéplatz 1, 10117 Berlin, Germany
- Collegium Medicum Berlin GmbH, Luisenstrasse 54/55, 10117 Berlin, Germany
| | - Raphael Mohr
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hepatology & Gastroenterology, Charité Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Werner Stenzel
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neuropathology, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Endres
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence, 10117 Berlin, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Center for Stroke Research Berlin, 10117 Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases, 10117 Berlin, Berlin, Germany
- DHZK (German Center for Cardiovascular Research), partner site Berlin, 10117 Berlin, Berlin, Germany
| | - Wolfgang Boehmerle
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence, 10117 Berlin, Berlin, Germany
| | - Petra Huehnchen
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence, 10117 Berlin, Berlin, Germany
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21
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Vicino A, Hottinger AF, Latifyan S, Boughdad S, Becce F, Prior JO, Kuntzer T, Brouland JP, Dunet V, Obeid M, Théaudin M. Immune checkpoint inhibitor-related myositis and myocarditis: diagnostic pitfalls and imaging contribution in a real-world, institutional case series. J Neurol 2024; 271:1947-1958. [PMID: 38141128 PMCID: PMC10973051 DOI: 10.1007/s00415-023-12134-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are reshaping the prognosis of many cancers, but often cause immune-related adverse events (irAEs). Among neurological irAEs, myositis is the most frequently reported. Our aim is to describe clinical and non-clinical characteristics, treatment and outcome of all irMyositis (skeletal limb-girdle and/or ocular myositis) and irMyocarditis cases in our reference center. METHODS We retrospectively enrolled all irMyositis/irMyocarditis patients seen between 2018 and 2022. We reviewed demographics, clinical characteristics, biological, neurophysiological, imaging workup, treatment and outcome. RESULTS We included 14 consecutive patients. The most frequent treatments were pembrolizumab (35%) or ipilimumab-nivolumab combination (35%). Limb-girdle, ocular (non-fluctuating palpebral ptosis and/or diplopia with or without ophthalmoparesis) and cardiac phenotypes were equally distributed, overlapping in 40% of cases. Ocular involvement was frequently misdiagnosed; review of brain MRIs disclosed initially missed signs of skeletal myositis in one patient and ocular myositis in 3. Seven patients had other co-existing irAEs. When performed, myography showed a myogenic pattern. CK was elevated in 8/15 patients, troponin-T in 12/12 and troponin-I in 7/9 tested patients. ICI were discontinued in all cases, with further immunosuppressive treatment in nine patients. In most cases, neurological and cardiological outcome was good at last follow-up. CONCLUSION Myositis is a potentially severe irAE. Despite its heterogeneous presentation, some highly suggestive clinical symptoms, such as ocular involvement, or radiological signs should raise physicians' attention to avoid misdiagnosis. We thus recommend a multidisciplinary assessment (including complete neuromuscular evaluation) even in case of isolated myocarditis. Our series underlines the importance of an early diagnosis, since suspension of ICI and adequate treatment are usually associated with good functional outcome.
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Affiliation(s)
- Alex Vicino
- Nerve-Muscle Unit, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Andreas F Hottinger
- Lundin Family Brain Tumor Center, Departments of Oncology and Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sofiya Latifyan
- Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah Boughdad
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John O Prior
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Kuntzer
- Nerve-Muscle Unit, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Philippe Brouland
- Pathology Institute, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michel Obeid
- Immunology and Allergy Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Marie Théaudin
- Nerve-Muscle Unit, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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22
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Fernández Jiménez-Ortiz H, Maroto Rodríguez B, Lapuente Monjas R, Sampedro Yáñez R, Sánchez Santos I, Toledano Fernández N. Iatrogenic affectation of ocular motility by immune checkpoint inhibitors. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2024; 99:158-164. [PMID: 38013131 DOI: 10.1016/j.oftale.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
Cancer therapy relies on new antitumoral drugs called immune checkpoint inhibitors (ICI), which produce long-lasting anti-tumor responses and lengthen survival, but cause autoimmune-type toxicity. The clinical characteristics induced by ICI are not well characterized to date and careful collection of clinical data is required to accurately define its safety profile. We conducted a literature search in the main clinical search engines to identify pharmacological ocular iatrogenic events of ICIs related to ocular motility. Four systematic reviews were found that included this type of ocular iatrogenesis as well as numerous isolated case reports. Reported adverse effects include: oculomotor paresis, optic neuropathy, optic atrophy, myastheniform syndromes, thyroid pseudo-orbitopathy, orbital apex syndrome, and hypophysitis. Most were managed without interruption or with partial interruption of cancer treatment. Aggressive systemic treatments were required for adequate management of ocular iatrogenic events. It is essential that the ophthalmologist become familiar with the new ICI oncological treatments, capable of causing severe and disabling motilidad ocular iatrogenesis for the patient. The communication of adverse effects and the report of the treatments used can help the most appropriate management of these patients. Research should be oriented towards complex differential diagnosis and to optimize decisions on cancer treatments.
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Affiliation(s)
| | - B Maroto Rodríguez
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - R Lapuente Monjas
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain.
| | - R Sampedro Yáñez
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | | | - N Toledano Fernández
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
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23
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Gilligan M, McGuigan C, McKeon A. Autoimmune central nervous system disorders: Antibody testing and its clinical utility. Clin Biochem 2024; 126:110746. [PMID: 38462203 PMCID: PMC11016295 DOI: 10.1016/j.clinbiochem.2024.110746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/16/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
A rapidly expanding repertoire of neural antibody biomarkers exists for autoimmune central nervous system (CNS) disorders. Following clinical recognition of an autoimmune CNS disorder, the detection of a neural antibody facilitates diagnosis and informs prognosis and management. This review considers the phenotypes, diagnostic assay methodologies, and clinical utility of neural antibodies in autoimmune CNS disorders. Autoimmune CNS disorders may present with a diverse range of clinical features. Clinical phenotype should inform the neural antibodies selected for testing via the use of phenotype-specific panels. Both serum and cerebrospinal fluid (CSF) are preferred in the vast majority of cases but for some analytes either CSF (e.g. N-methyl-D-aspartate receptor [NMDA-R] IgG) or serum (e.g. aquaporin-4 [AQP4] IgG) specimens may be preferred. Screening using 2 methods is recommended for most analytes, particularly paraneoplastic antibodies. We utilize murine tissue-based indirect immunofluorescence assay (TIFA) with subsequent confirmatory protein-specific testing. The cellular location of the target antigen informs choice of confirmatory diagnostic assay (e.g. blot for intracellular antigens such as Hu; cell-based assay for cell surface targets such as leucine-rich glioma inactivated 1 [LGI1]). Titers of positive results have limited diagnostic utility with the exception of glutamic acid decarboxylase (GAD) 65 IgG autoimmunity, which is associated with neurological disease at higher values. While novel antibodies are typically discovered using established techniques such as TIFA and immunoprecipitation-mass spectrometry, more recent high-throughput molecular technologies (such as protein microarray and phage-display immunoprecipitation sequencing) may expedite the process of antibody discovery. Individual neural antibodies inform the clinician regarding the clinical associations, oncological risk stratification and tumor histology, the likely prognosis, and immunotherapy choice. In the era of neural antibody biomarkers for autoimmune CNS disorders, access to appropriate laboratory assays for neural antibodies is of critical importance in the diagnosis and management of these disorders.
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Affiliation(s)
- Michael Gilligan
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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24
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Sarkar A, Nagappa M, Dey S, Mondal S, Babu GS, Choudhury SP, Akhil P, Debnath M. Synergistic effects of immune checkpoints and checkpoint inhibitors in inflammatory neuropathies: Implications and mechanisms. J Peripher Nerv Syst 2024; 29:6-16. [PMID: 37988274 DOI: 10.1111/jns.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 11/23/2023]
Abstract
Immune checkpoint molecules play pivotal roles in the regulation of immune homeostasis. Disruption of the immune checkpoints causes autoimmune/inflammatory as well as malignant disorders. Over the past few years, the immune checkpoint molecules with inhibitory function emerged as potential therapeutic targets in oncological conditions. The inhibition of the function of these molecules by using immune checkpoint inhibitors (ICIs) has brought paradigmatic changes in cancer therapy due to their remarkable clinical benefits, not only in improving the quality of life but also in prolonging the survival time of cancer patients. Unfortunately, the ICIs soon turned out to be a "double-edged sword" as the use of ICIs caused multiple immune-related adverse effects (irAEs). The development of inflammatory neuropathies such as Guillain-Barré syndrome (GBS) and Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) as the secondary effects of immunotherapy appeared very challenging as these conditions result in significant and often permanent disability. The underlying mechanism(s) through which ICIs trigger inflammatory neuropathies are currently not known. Compelling evidence suggests autoimmune reaction and/or inflammation as the independent risk mechanism of inflammatory neuropathies. There is a lack of understanding as to whether prior exposure to the risk factors of inflammatory neuropathies, the presence of germline genetic variants in immune function-related genes, genetic variations within immune checkpoint molecules, the existence of autoantibodies, and activated/memory T cells act as determining factors for ICI-induced inflammatory neuropathies. Herein, we highlight the available pieces of evidence, discuss the mechanistic basis, and propose a few testable hypotheses on inflammatory neuropathies as irAEs of immunotherapy.
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Affiliation(s)
- Aritrani Sarkar
- Department of Human Genetics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Saikat Dey
- Department of Human Genetics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Sandipan Mondal
- Department of Human Genetics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Gopika Suresh Babu
- Department of Human Genetics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Saptamita Pal Choudhury
- Department of Human Genetics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Pokala Akhil
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Monojit Debnath
- Department of Human Genetics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
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Yan T, Yu L, Zhang J, Chen Y, Fu Y, Tang J, Liao D. Achilles' Heel of currently approved immune checkpoint inhibitors: immune related adverse events. Front Immunol 2024; 15:1292122. [PMID: 38410506 PMCID: PMC10895024 DOI: 10.3389/fimmu.2024.1292122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/04/2024] [Indexed: 02/28/2024] Open
Abstract
Immunotherapy has revolutionized the cancer treatment landscape by opening up novel avenues for intervention. As the use of immune checkpoint inhibitors (ICIs) has exponentially increased, so have immune-related adverse events (irAEs). The mechanism of irAEs may involve the direct damage caused by monoclonal antibodies and a sequence of immune responses triggered by T cell activation. Common side effects include dermatologic toxicity, endocrine toxicity, gastrointestinal toxicity, and hepatic toxicity. While relatively rare, neurotoxicity, cardiotoxicity, and pulmonary toxicity can be fatal. These toxicities pose a clinical dilemma regarding treatment discontinuation since they can result in severe complications and necessitate frequent hospitalization. Vigilant monitoring of irAEs is vital in clinical practice, and the principal therapeutic strategy entails the administration of oral or intravenous glucocorticoids (GSCs). It may be necessary to temporarily or permanently discontinue the use of ICIs in severe cases. Given that irAEs can impact multiple organs and require diverse treatment approaches, the involvement of a multidisciplinary team of experts is imperative. This review aims to comprehensively examine the pathogenesis, clinical manifestations, incidence, and treatment options for various irAEs.
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Affiliation(s)
- Ting Yan
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Lun Yu
- Department of Positron Emission Tomography–Computed Tomography (PET-CT) Center, Chenzhou No. 1 People’s Hospital, Chenzhou, China
| | - Jiwen Zhang
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
- School of Pharmacy, University of South China, Hengyang, China
| | - Yun Chen
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yilan Fu
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Jingyi Tang
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Dehua Liao
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
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Müller-Jensen L, Schulz AR, Mei HE, Mohr R, Ulrich C, Knape P, Frost N, Frischbutter S, Kunkel D, Schinke C, Ginesta Roque L, Maierhof SK, Nickel FT, Heinzerling L, Endres M, Boehmerle W, Huehnchen P, Knauss S. Immune signatures of checkpoint inhibitor-induced autoimmunity-A focus on neurotoxicity. Neuro Oncol 2024; 26:279-294. [PMID: 37823709 PMCID: PMC10836772 DOI: 10.1093/neuonc/noad198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Neurologic immune-related adverse events (irAE-n) are rare but severe toxicities of immune checkpoint inhibitor (ICI) treatment. To overcome diagnostic and therapeutic challenges, a better mechanistic understanding of irAE-n is paramount. METHODS In this observational cohort study, we collected serum and peripheral blood samples from 34 consecutive cancer patients with irAE-n (during acute illness) and 49 cancer control patients without irAE-n (pre- and on-ICI treatment, n = 44 without high-grade irAEs, n = 5 with high-grade nonneurologic irAEs). Patients received either anti-programmed cell death protein (PD)-1 or anti-PD ligand-1 monotherapy or anti-PD-1/anti-cytotoxic T-lymphocyte-associated protein-4 combination therapy. Most common cancers were melanoma, lung cancer, and hepatocellular carcinoma. Peripheral blood immune profiling was performed using 48-marker single-cell mass cytometry and a multiplex cytokine assay. RESULTS During acute illness, patients with irAE-n presented higher frequencies of cluster of differentiation (CD)8+ effector memory type (EM-)1 and central memory (CM) T cells compared to controls without irAEs. Multiorgan immunotoxicities (neurologic + nonneurologic) were associated with higher CD8+ EM1 T cell counts. While there were no B cell changes in the overall cohort, we detected a marked decrease of IgD- CD11c+ CD21low and IgD- CD24+ CD21high B cells in a subgroup of patients with autoantibody-positive irAE-n. We further identified signatures indicative of enhanced chemotaxis and inflammation in irAE-n patients and discovered C-X-C motif chemokine ligand (CXCL)10 as a promising marker to diagnose high-grade immunotoxicities such as irAE-n. CONCLUSIONS We demonstrate profound and partly subgroup-specific immune cell dysregulation in irAE-n patients, which may guide future biomarker development and targeted treatment approaches.
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Affiliation(s)
- Leonie Müller-Jensen
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Axel R Schulz
- Mass Cytometry Laboratory, German Rheumatism Research Center (DRFZ), A Leibniz Institute, Berlin, Germany
| | - Henrik E Mei
- Mass Cytometry Laboratory, German Rheumatism Research Center (DRFZ), A Leibniz Institute, Berlin, Germany
| | - Raphael Mohr
- Department of Hepatology and Gastroenterology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Claas Ulrich
- Department of Dermatology, Venerology, and Allergology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Collegium Medicum Berlin GmbH, Berlin, Germany
| | - Philipp Knape
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Nikolaj Frost
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Frischbutter
- Institute of Allergology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Desiree Kunkel
- Flow and Mass Cytometry Core Facility, Berlin Institute of Health at Charité – Univeritätsmedizin Berlin, Berlin, Germany
| | - Christian Schinke
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Lorena Ginesta Roque
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Smilla K Maierhof
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin (ECN) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Florian T Nickel
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, München, Germany
- Department of Dermatology and Allergy, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Wolfgang Boehmerle
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Petra Huehnchen
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Samuel Knauss
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
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27
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Bjursten S, Zhao Z, Al Remawi H, Studahl M, Pandita A, Simrén J, Zetterberg H, Lundell AC, Rudin A, Ny L, Levin M. Concentrations of S100B and neurofilament light chain in blood as biomarkers for checkpoint inhibitor-induced CNS inflammation. EBioMedicine 2024; 100:104955. [PMID: 38171113 PMCID: PMC10796943 DOI: 10.1016/j.ebiom.2023.104955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Cancer treatment with immune checkpoint inhibition (ICI) can cause immune-related adverse events in the central nervous system (CNS irAE). There are no blood biomarkers to detect CNS irAE. We investigated if concentrations of S100-calcium-binding protein B (S100B) and neurofilament light chain (NfL) in blood can be used as biomarkers for CNS irAE and assessed the incidence of CNS irAE in a cohort of ICI-treated patients. METHODS In this single-centre, retrospective cohort study, we examined medical records and laboratory data of 197 consecutive patients treated with combined CTLA-4 and PD-1 inhibition (ipilimumab; ipi + nivolumab; nivo) for metastatic melanoma or renal cell carcinoma. CNS irAE was diagnosed using established criteria. Concentrations of S100B and NfL in blood were measured in patients with CNS irAE and in 84 patients without CNS irAE. FINDINGS Nine of 197 patients (4.6%) fulfilled criteria for CNS irAE. S100B and NfL in blood increased during CNS inflammation and normalized during immunosuppression. CNS irAE was detected with a sensitivity of 100% (S100B) and 79% (NfL) and a specificity of 89% (S100B) and 74% (NfL). Patients with CNS irAE had simultaneous increased concentration of C-reactive protein (CRP) (9/9) and alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) in blood (8/9). INTERPRETATION Analysis of S100B, NfL and CRP in blood facilitates the diagnosis of CNS irAE. CNS irAE may be more common than previously reported. There may be shared immune mechanisms between CNS and hepatitis irAE. FUNDING Supported by funding from the Swedish Cancer Foundation, the ALF-agreement, and Jubileumsklinikens Cancerfond.
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Affiliation(s)
- Sara Bjursten
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Zhiyuan Zhao
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hifaa Al Remawi
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie Studahl
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ankur Pandita
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joel Simrén
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK; UK Dementia Research Institute at UCL, London, UK; Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Anna-Carin Lundell
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Rudin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Ny
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Max Levin
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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28
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Farina A, Escalere M, Dion M, Moussy M, Pegat A, Villagrán-García M, Devic P, Lamiral A, Seyve A, Aure K, Wang A, Gorza L, Streichenberger N, Maisonobe T, Honnorat J, Birzu C, Psimaras D, Weisenburger-Lile D, Joubert B. Mononeuritis multiplex following immune checkpoint inhibitors in malignant pleural mesothelioma. Front Neurol 2024; 15:1338899. [PMID: 38333608 PMCID: PMC10850347 DOI: 10.3389/fneur.2024.1338899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
Introduction Mononeuritis multiplex is frequently related to vasculitic neuropathy and has been reported only sporadically as an adverse event of immune checkpoint inhibitors. Methods Case series of three patients with mononeuritis multiplex-all with mesothelioma-identified in the databases of two French clinical networks (French Reference Center for Paraneoplastic Neurological Syndromes, Lyon; OncoNeuroTox, Paris; January 2015-October 2022) set up to collect and investigate n-irAEs on a nationwide level. Results Three patients (male; median age 86 years; range 72-88 years) had pleural mesothelioma and received 10, 4, and 6 cycles, respectively, of first-line nivolumab plus ipilimumab combined therapy. In patient 1, the neurological symptoms involved the median nerves, and in the other two patients, there was a more diffuse distribution; the symptoms were severe (common terminology criteria for adverse events, CTCAE grade 3) in all patients. Nerve conduction studies indicated mononeuritis multiplex in all patients. Peripheral nerve biopsy demonstrated necrotizing vasculitis in patients 1 and 3 and marked IgA deposition without inflammatory lesions in patient 2. Immune checkpoint inhibitors were permanently withdrawn, and corticosteroids were administered to all patients, leading to complete symptom regression (CTCAE grade 0, patient 2) or partial improvement (CTCAE grade 2, patients 1 and 3). During steroid tapering, patient 1 experienced symptom recurrence and spreading to other nerve territories (CTCAE grade 3); he improved 3 months after rituximab and cyclophosphamide administration. Discussion We report the occurrence of mononeuritis multiplex, a very rare adverse event of immune checkpoint inhibitors, in the three patients with mesothelioma. Clinicians must be aware of this severe, yet treatable adverse event.
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Affiliation(s)
- Antonio Farina
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS—UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Manon Escalere
- Unité de Neurologie et de Neurovasculaire, Foch Hospital, Suresnes, France
| | - Matthias Dion
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
| | - Martin Moussy
- Service de Neurologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Antoine Pegat
- Service ENMG et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Macarena Villagrán-García
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS—UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Perrine Devic
- Service de Neurologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Anaïde Lamiral
- Service de Neurologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Antoine Seyve
- Service de Neuro-Oncologie, Hôpital Neurologique, Hospices Civils de Lyon, Lyon, France
| | - Karine Aure
- Unité de Neurologie et de Neurovasculaire, Foch Hospital, Suresnes, France
| | - Adrien Wang
- Unité de Neurologie et de Neurovasculaire, Foch Hospital, Suresnes, France
| | - Lucas Gorza
- Unité de Neurologie et de Neurovasculaire, Foch Hospital, Suresnes, France
| | - Nathalie Streichenberger
- Service de Neuropathologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Institut NeuroMyogène, CNRS UMR 5261—INSERM U1315, Lyon, France
| | - Thierry Maisonobe
- Département de Neurophysiologie Clinique, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Jerome Honnorat
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS—UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Cristina Birzu
- Sorbonne Université, Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France
- INSERM, CNRS, Assistance Publique-Hôpitaux de Paris, Institut du Cerveau Et de La Moelle Épinière, Sorbonne Université, Paris, France
| | - Dimitri Psimaras
- Sorbonne Université, Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France
- INSERM, CNRS, Assistance Publique-Hôpitaux de Paris, Institut du Cerveau Et de La Moelle Épinière, Sorbonne Université, Paris, France
| | | | - Bastien Joubert
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS—UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
- Service de Neurologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
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McCombe JA, Sechi E, Zekeridou A. Neurologic manifestations of autoimmunity with immune checkpoint inhibitors. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:449-465. [PMID: 38494296 DOI: 10.1016/b978-0-12-823912-4.00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Immune checkpoint inhibitors (ICIs) are cancer immunotherapies that enhance the body's own immune system to treat cancer. ICI treatment, however, can cause immune-related adverse events (irAEs) that can affect any organ, resulting in significant morbidity and mortality. Neurologic irAEs (nirAEs) are rare and can affect the peripheral nervous system more commonly than the central nervous system. Treatment is dependent on the severity of the neurologic manifestations and often includs discontinuation of the ICI and initiation of steroid therapy as the first line; other treatments have also been used. NirAEs and cardiac irAEs have higher fatality rates underlying the importance of early recognition and appropriate management. This chapter reviews the clinical manifestations of neurologic immune-related adverse events associated with ICI treatment as well as diagnostic and therapeutic modalities.
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Affiliation(s)
- Jennifer A McCombe
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States.
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Farina A, Villagrán-García M, Vogrig A, Zekeridou A, Muñiz-Castrillo S, Velasco R, Guidon AC, Joubert B, Honnorat J. Neurological adverse events of immune checkpoint inhibitors and the development of paraneoplastic neurological syndromes. Lancet Neurol 2024; 23:81-94. [PMID: 38101905 DOI: 10.1016/s1474-4422(23)00369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 12/17/2023]
Abstract
Immune checkpoint inhibitors, a class of oncological treatments that enhance antitumour immunity, can trigger neurological adverse events closely resembling paraneoplastic neurological syndromes. Unlike other neurological adverse events caused by these drugs, post-immune checkpoint inhibitor paraneoplastic neurological syndromes predominantly affect the CNS and are associated with neural antibodies and cancer types commonly found also in spontaneous paraneoplastic neurological syndromes. Furthermore, post-immune checkpoint inhibitor paraneoplastic neurological syndromes have poorer neurological outcomes than other neurological adverse events of immune checkpoint inhibitors. Early diagnosis and initiation of immunosuppressive therapy are likely to be crucial in preventing the accumulation of neurological disability. Importantly, the neural antibodies found in patients with post-immune checkpoint inhibitor paraneoplastic neurological syndromes are sometimes detected before treatment, indicating that these antibodies might help to predict the development of neurological adverse events. Experimental and clinical evidence suggests that post-immune checkpoint inhibitor paraneoplastic neurological syndromes probably share immunological features with spontaneous paraneoplastic syndromes. Hence, the study of post-immune checkpoint inhibitor paraneoplastic neurological syndromes can help in deciphering the immunopathogenesis of paraneoplastic neurological syndromes and in identifying novel therapeutic targets.
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Affiliation(s)
- Antonio Farina
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - Macarena Villagrán-García
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy; Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sergio Muñiz-Castrillo
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Stanford Center for Sleep Sciences and Medicine, Palo Alto, CA, USA
| | - Roser Velasco
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d'Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain; Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Amanda C Guidon
- Harvard Medical School, Boston, MA, USA; Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bastien Joubert
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Department of Neurology, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jérôme Honnorat
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France.
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Briani C, Visentin A. Hematologic malignancies and hematopoietic stem cell transplantation. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:419-429. [PMID: 38494294 DOI: 10.1016/b978-0-12-823912-4.00016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes are rarely associated with hematologic malignancies. In their rarity, lymphomas are the diseases with more frequent paraneoplastic neurologic syndrome. High-risk antibodies are absent in most lymphoma-associated paraneoplastic neurologic syndromes, with the exception of antibodies to Tr/DNER in paraneoplastic cerebellar degeneration, mGluR5 in limbic encephalitis, and mGluR1 in some cerebellar ataxias. Peripheral nervous system paraneoplastic neurologic syndromes are rare and heterogeneous, with a prevalence of demyelinating polyradiculoneuropathy in non-Hodgkin lymphoma. Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) is a rare, paraneoplastic syndrome due to an underlying plasma cell disorder. The diagnosis is based on defined criteria, and vascular endothelial growth factor (VEGF), not an antibody, is considered a reliable diagnostic marker that also mirrors therapy response. As with the paraneoplastic neurologic syndromes in solid tumors, therapies rely on cancer treatment associated with immunomodulatory treatment with better response in PNS with antibodies to surface antigens. The best outcome is generally present in Ophelia syndrome/limbic encephalitis with anti-mGluR5 antibodies, with frequent complete recovery. Besides patients with isolated osteosclerotic lesions (where radiotherapy is indicated), hematopoietic stem-cell transplantation is the therapy of choice in patients with POEMS syndrome. In the paraneoplastic neurologic syndromes secondary to immune checkpoint inhibitors, discontinuation of the drug together with immunomodulatory treatment is recommended.
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Affiliation(s)
- Chiara Briani
- Department of Neurosciences, Neurology Unit, University of Padova, Padova, Italy.
| | - Andrea Visentin
- Department of Medicine, Hematology Unit, University of Padova, Padova, Italy
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Shelly S, Dubey D, Mills JR, Klein CJ. Paraneoplastic neuropathies and peripheral nerve hyperexcitability disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:239-273. [PMID: 38494281 DOI: 10.1016/b978-0-12-823912-4.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Peripheral neuropathy is a common referral for patients to the neurologic clinics. Paraneoplastic neuropathies account for a small but high morbidity and mortality subgroup. Symptoms include weakness, sensory loss, sweating irregularity, blood pressure instability, severe constipation, and neuropathic pain. Neuropathy is the first presenting symptom of malignancy among many patients. The molecular and cellular oncogenic immune targets reside within cell bodies, axons, cytoplasms, or surface membranes of neural tissues. A more favorable immune treatment outcome occurs in those where the targets reside on the cell surface. Patients with antibodies binding cell surface antigens commonly have neural hyperexcitability with pain, cramps, fasciculations, and hyperhidrotic attacks (CASPR2, LGI1, and others). The antigenic targets are also commonly expressed in the central nervous system, with presenting symptoms being myelopathy, encephalopathy, and seizures with neuropathy, often masked. Pain and autonomic components typically relate to small nerve fiber involvement (nociceptive, adrenergic, enteric, and sudomotor), sometimes without nerve fiber loss but rather hyperexcitability. The specific antibodies discovered help direct cancer investigations. Among the primary axonal paraneoplastic neuropathies, pathognomonic clinical features do not exist, and testing for multiple antibodies simultaneously provides the best sensitivity in testing (AGNA1-SOX1; amphiphysin; ANNA-1-HU; ANNA-3-DACH1; CASPR2; CRMP5; LGI1; PCA2-MAP1B, and others). Performing confirmatory antibody testing using adjunct methods improves specificity. Antibody-mediated demyelinating paraneoplastic neuropathies are limited to MAG-IgM (IgM-MGUS, Waldenström's, and myeloma), with the others associated with cytokine elevations (VEGF, IL6) caused by osteosclerotic myeloma, plasmacytoma (POEMS), and rarely angiofollicular lymphoma (Castleman's). Paraneoplastic disorders have clinical overlap with other idiopathic antibody disorders, including IgG4 demyelinating nodopathies (NF155 and Contactin-1). This review summarizes the paraneoplastic neuropathies, including those with peripheral nerve hyperexcitability.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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Pepys J, Stoff R, Ramon-Gonen R, Ben-Betzalel G, Grynberg S, Frommer RS, Schachter J, Asher N, Taliansky A, Nikitin V, Dori A, Shelly S. Incidence and Outcome of Neurologic Immune-Related Adverse Events Associated With Immune Checkpoint Inhibitors in Patients With Melanoma. Neurology 2023; 101:e2472-e2482. [PMID: 37652699 PMCID: PMC10791056 DOI: 10.1212/wnl.0000000000207632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/30/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neurologic immune-related adverse events (n-irAEs) reportedly occur in up to 8% of patients treated with immune checkpoint inhibitors (ICIs) of all age groups. We investigated the association between age and n-irAEs in patients treated with ICIs and examined the effect of n-irAEs on survival outcomes in a large cohort of patients with melanoma. METHODS We conducted a retrospective analysis of patients with advanced melanoma treated with ICIs at Ella Institute for Immuno-oncology and Melanoma between January 1, 2015, and April 20, 2022. The outcomes of interest were defined as the investigation of age-related frequency and severity of n-irAEs, the need for ICI interruption, the treatment required for n-irAE management, the safety of ICI reintroduction, and n-irAE's effect on survival. RESULTS ICI was administered to 937 patients. At least one irAE occurred in 73.5% (n = 689) of them. Among the study population, 8% (n = 76) developed a n-irAE, with a median age of 66 years in female and 68 years in male patients at onset. The median follow-up after n-irAE was 1,147 days (IQR: 1,091.5 range: 3,938). Fewer irAEs occurred in patients older than 70 years (median: 3 events, p = 0.04, CI 2.5-4.7) while specifically colitis and pneumonitis were more common in the 18-60 age group (p = 0.03, 95% CI 0.8-0.38, p = 0.009, 95% CI 0.06-0.2). Grade ≥ 3 toxicity was seen in 35.5% of patients across age groups. The median time from ICI administration to n-irAE development was 48 days across age groups. Common n-irAE phenotypes were myositis (44.7%), encephalitis (10.5%), and neuropathy (10.5%). N-irAE required hospitalization in 40% of patients and steroids treatment in 46% with a median of 4 days from n-irAE diagnosis to steroids treatment initiation. Nine patients needed second-line immunosuppressive treatment. Rechallenge did not cause additional n-irAE in 71% of patients. Developing n-irAE (HR = 0.4, 95% CI 0.32-0.77) or any irAE (HR = 0.7195% CI 0.56-0.88) was associated with longer survival. DISCUSSION N-irAEs are a relatively common complication of ICIs (8% of our cohort). Older age was not associated with its development or severity, in contrast with non-n-irAEs which occurred less frequently in the elderly population. Rechallenge did not result in life-threatening AEs. Development of any irAEs was associated with longer survival; this association was stronger with n-irAEs.
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Affiliation(s)
- Jack Pepys
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Ronen Stoff
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Roni Ramon-Gonen
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Guy Ben-Betzalel
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Shirly Grynberg
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Ronnie Shapira Frommer
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Jacob Schachter
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Nethanel Asher
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Alisa Taliansky
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Vera Nikitin
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Dori
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
| | - Shahar Shelly
- From the Department of Biomedical Sciences (J.P.), Humanitas University, Milan, Italy; Ella Institute for Immuno-Oncology and Melanoma (R.S., G.B.-B., S.G., R.S.F., J.S., N.A.), Sheba Medical Center; Department of Neurology and Neurosurgery (R.S., G.B.-B., S.G., R.S.F., J.S., N.A., A.T., V.N., A.D.), Sackler Faculty of Medicine, Tel Aviv University; The Graduate School of Business Administration (R.R.-G.), Bar-Ilan University; Department of Neurology (A.T., V.N., A.D.), Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology Mayo Clinic (S.S.), Rochester, MN; Department of Neurology (S.S.), Rambam Medical Center; and Rappaport Faculty of Medicine (S.S.), Technion-Israel Institute of Technology, Haifa, Israel
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Song KW, Scott BJ, Lee EQ. Neurotoxicity of Cancer Immunotherapies Including CAR T Cell Therapy. Curr Neurol Neurosci Rep 2023; 23:827-839. [PMID: 37938472 DOI: 10.1007/s11910-023-01315-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE OF REVIEW To outline the spectrum of neurotoxicity seen with approved immunotherapies and in pivotal clinical trials including immune checkpoint inhibitors, chimeric antigen receptor T-cell therapy, vaccine therapy, and oncolytic viruses. RECENT FINDINGS There has been an exponential growth in new immunotherapies, which has transformed the landscape of oncology treatment. With more widespread use of cancer immunotherapies, there have also been advances in characterization of its associated neurotoxicity, research into potential underlying mechanisms, and development of management guidelines. Increasingly, there is also mounting interest in long-term neurologic sequelae. Neurologic complications of immunotherapy can impact every aspect of the central and peripheral nervous system. Early recognition and treatment are critical. Expanding indications for immunotherapy to solid and CNS tumors has led to new challenges, such as how to reliably distinguish neurotoxicity from disease progression. Our evolving understanding of immunotherapy neurotoxicity highlights important areas for future research and the need for novel immunomodulatory therapeutics.
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Affiliation(s)
- Kun-Wei Song
- Department of Neurology, Stanford University School of Medicine, 453 Quarry Rd, 2nd Floor, Stanford, CA, 94305, USA.
| | - Brian J Scott
- Department of Neurology, Stanford University School of Medicine, 453 Quarry Rd, 2nd Floor, Stanford, CA, 94305, USA
| | - Eudocia Q Lee
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
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Fonseca E, Cabrera-Maqueda JM, Ruiz-García R, Naranjo L, Diaz-Pedroche C, Velasco R, Macias-Gómez A, Milisenda JC, Muñoz-Farjas E, Pascual-Goñi E, Gállego Perez-Larraya J, Saiz A, Dalmau J, Blanco Y, Graus F, Martinez-Hernandez E. Neurological adverse events related to immune-checkpoint inhibitors in Spain: a retrospective cohort study. Lancet Neurol 2023; 22:1150-1159. [PMID: 37977714 DOI: 10.1016/s1474-4422(23)00335-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/07/2023] [Accepted: 08/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Neurological immune-related adverse events associated with immune checkpoint inhibitors can have several clinical manifestations, but the syndromes and prognostic factors are still not well known. We aimed to characterise and group the clinical features, with a special focus in patients presenting with encephalopathy, and to identify predictors of response to therapy and survival. METHODS This retrospective observational study included patients with neurological immune-related adverse events from 20 hospitals in Spain whose clinical information, serum samples, and CSF samples were studied at Hospital Clinic de Barcelona, Barcelona, Spain. Patients with pre-existing paraneoplastic syndromes or evidence of alternative causes for their neurological symptoms were excluded. We reviewed the clinical information, classified their clinical features, and determined the presence of neural antibodies. Neurological status was assessed by the treating physician one month after adverse event onset (as improvement vs no improvement) and at the last evaluation (complete recovery or modified Rankin Scale score decrease of at least 2 points, indicating good outcome, vs all other modified Rankin Scale scores, indicating poor outcome); if the participant had died, the date and cause of death were recorded. We used Fisher's exact tests and Mann-Whitney U tests to analyse clinical features, and multivariable logistic regression to analyse prognostic factors. FINDINGS From Jan 1, 2018, until Feb 1, 2023, 83 patients with suspected neurological immune-related adverse events after use of immune checkpoint inhibitors were identified, of whom 64 patients were included. These patients had a median age of 67 years (IQR 59-74); 42 (66%) were male and 22 (34%) were female. The predominant tumours were lung cancer (30 [47%] patients), melanoma (13 [21%] patients), and renal cell carcinoma (seven [11%] patients). Neural antibodies were detected in 14 (22%) patients; 52 (81%) patients had CNS involvement and 12 (19%) had peripheral nervous system involvement. Encephalopathy occurred in 45 (70%) patients, 12 (27%) of whom had antibodies or well defined syndromes consistent with definite paraneoplastic or autoimmune encephalitis, 24 (53%) of whom had encephalitis without antibodies or clinical features characteristic of a defined syndrome, and nine (20%) of whom had encephalopathy without antibodies or inflammatory changes in CSF or brain MRI. Nine (14%) of 64 patients had combined myasthenia and myositis, five of them with myocarditis. Even though 58 (91%) of 64 patients received steroids and 31 (48%) of 64 received additional therapies, 18 (28%) did not improve during the first month after adverse event onset, and 11 of these 18 people died. At the last follow-up for the 53 remaining patients (median 6 months, IQR 3-13), 20 (38%) had a poor outcome (16 deaths, one related to a neurological immune-related adverse event). Mortality risk was increased in patients with lung cancer (vs those with other cancers: HR 2·5, 95% CI 1·1-6·0) and in patients with encephalopathy without evidence of CNS inflammation or combined myocarditis, myasthenia, and myositis (vs those with the remaining syndromes: HR 5·0, 1·4-17·8 and HR 6·6, 1·4-31·0, respectively). INTERPRETATION Most neurological immune-related adverse events involved the CNS and were antibody negative. The presence of myocarditis, myasthenia, and myositis, of encephalopathy without inflammatory changes, or of lung cancer were independent predictors of death. Most deaths occurred during the first month of symptom onset. If our findings are replicated in additional cohorts, they could confirm that these patients need early and intensive treatment. FUNDING The Instituto de Salud Carlos III and the European Union.
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Affiliation(s)
- Elianet Fonseca
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jose M Cabrera-Maqueda
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Raquel Ruiz-García
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Immunology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Laura Naranjo
- Department of Immunology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Carmen Diaz-Pedroche
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Roser Velasco
- Department of Neurology, Hospital Universitari de Bellvitge-Institut Catalàd'Oncologia, l'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Jose C Milisenda
- Department of Internal Medicine, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Elena Muñoz-Farjas
- Department of Neurology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Elba Pascual-Goñi
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona Spain
| | | | - Albert Saiz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Yolanda Blanco
- Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Eugenia Martinez-Hernandez
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.
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Kang Y, Zhen H, Ma N, Zhao H, Cao B. Encephalitis in a patient with hypopharynx cancer treated with immune checkpoint inhibitors and radiotherapy: a case report and review of the literature. J Cancer Res Clin Oncol 2023; 149:16239-16246. [PMID: 37676267 PMCID: PMC10620264 DOI: 10.1007/s00432-023-05328-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 08/21/2023] [Indexed: 09/08/2023]
Abstract
Hypopharyngeal cancer (HPC) has one of the most unfavorable prognoses among head and neck squamous cell carcinomas. Immunotherapy in combination with chemotherapy, the same as conventional induction chemotherapy, has emerged as a vital part of the induction therapy protocol for HPC. Meanwhile, the incidence of immune-related adverse events is increasing. In this light, we present the first reported case of immune-associated encephalitis in a patient with hypopharyngeal cancer treated with Camrelizumab (a PD-1 inhibitor). After receiving immunotherapy combined with chemotherapy as induction therapy, along with concurrent chemoradiotherapy, the patient presented with symptoms of fatigue, tremors, drowsiness, and an abnormal signal in the right temporal lobe as shown on a brain magnetic resonance imaging (MRI). Despite the minor elevation in protein and IgG index observed in the lumbar puncture, there is no evidence of abnormal autoantibodies or evidence of pathogenic infection. Following a thorough multidisciplinary consultation, the patient is suspected to be afflicted with immune-related autoimmune encephalitis. Intravenous methylprednisolone was prescribed as an empirical treatment at an initial dosage of 120 mg/day for 3 days, followed by steroid tapering. Finally, the patient experienced complete neurologic and radiographic (brain MRI) recovery. This case serves as a critical reminder that encephalitis is a potential diagnosis that should never be overlooked in patients undergoing immunotherapy who present with abnormal signs of the brain. The timely diagnosis and initiation of immunosuppressive therapy are key components of treating ICI-associated encephalitis.
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Affiliation(s)
- Yan Kang
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Hongchao Zhen
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Nina Ma
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Hong Zhao
- Department of Radiotherapy, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Bangwei Cao
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China.
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McNeish BL, Kolb N. Toxic Neuropathies. Continuum (Minneap Minn) 2023; 29:1444-1468. [PMID: 37851038 DOI: 10.1212/con.0000000000001343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE The purpose of this article is to provide an overview and update on the most clinically relevant toxic neuropathies. LATEST DEVELOPMENTS Broadly, toxic neuropathies were previously quite rare with the notable exception of neuropathy from alcohol or older chemotherapeutics. The development of newer therapies, particularly immunotherapy to treat malignancy, has resulted in a substantial increase in the occurrence of toxic neuropathies that require timely recognition and treatment. The understanding of other toxic neuropathies continues to evolve, such as statin-induced neuropathy, which new evidence suggests is much less common than previously suspected. ESSENTIAL POINTS Toxic neuropathies can be caused by medications, supplements, and recreational substances that injure peripheral nerves. Medications have evolved in the past 2 decades, as have the types of neuropathies that can be seen as related toxicities. In some areas of medicine, new classes and generations of drugs are associated with a lower incidence of toxic neuropathy.
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Yun HD, Goel Y, Gupta K. Crosstalk of Mast Cells and Natural Killer Cells with Neurons in Chemotherapy-Induced Peripheral Neuropathy. Int J Mol Sci 2023; 24:12543. [PMID: 37628724 PMCID: PMC10454469 DOI: 10.3390/ijms241612543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/04/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Chemotherapy-induced peripheral neuropathy (CIPN) is a major comorbidity of cancer. Multiple clinical interventions have been studied to effectively treat CIPN, but the results have been disappointing, with no or little efficacy. Hence, understanding the pathophysiology of CIPN is critical to improving the quality of life and clinical outcomes of cancer patients. Although various mechanisms of CIPN have been described in neuropathic anti-cancer agents, the neuroinflammatory process involving cytotoxic/proinflammatory immune cells remains underexamined. While mast cells (MCs) and natural killer (NK) cells are the key innate immune compartments implicated in the pathogenesis of peripheral neuropathy, their role in CIPN has remained under-appreciated. Moreover, the biology of proinflammatory cytokines associated with MCs and NK cells in CIPN is particularly under-evaluated. In this review, we will focus on the interactions between MCs, NK cells, and neuronal structure and their communications via proinflammatory cytokines, including TNFα, IL-1β, and IL-6, in peripheral neuropathy in association with tumor immunology. This review will help lay the foundation to investigate MCs, NK cells, and cytokines to advance future therapeutic strategies for CIPN.
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Affiliation(s)
- Hyun Don Yun
- Hematology, Oncology, Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
- Division of Hematology, Oncology, Department of Medicine, School of Medicine, University of California, Irvine, CA 92617, USA; (Y.G.); (K.G.)
| | - Yugal Goel
- Division of Hematology, Oncology, Department of Medicine, School of Medicine, University of California, Irvine, CA 92617, USA; (Y.G.); (K.G.)
| | - Kalpna Gupta
- Division of Hematology, Oncology, Department of Medicine, School of Medicine, University of California, Irvine, CA 92617, USA; (Y.G.); (K.G.)
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Hyun JW, Kim KH, Kim SH, Kim HJ. Severe neuromuscular immune-related adverse events of immune checkpoint inhibitors at national cancer center in Korea. J Cancer Res Clin Oncol 2023; 149:5583-5589. [PMID: 36495331 PMCID: PMC10356664 DOI: 10.1007/s00432-022-04516-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Neuromuscular immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICIs) have been increasingly recognized as a consequence of expanding use of ICIs in advanced cancers. We aimed to evaluate the frequency, phenotypes, rescue treatment, and clinical outcomes of severe neuromuscular irAEs of ICIs at National Cancer Center (NCC), Korea. MATERIALS AND METHODS Consecutive patients with newly developed severe neuromuscular irAEs (common terminology criteria for adverse events grade 3 or greater) after ICI treatment at NCC in Korea between December 2018 and April 2022 were included by searching neuromuscular diagnostic codes in electronic medical records and/or reviewing neurological consultation documentations. RESULTS Of the 1,503 ICI-treated patients, nine (0.6%) experienced severe neuromuscular irAEs; five with pembrolizumab and four with atezolizumab. The patients included five women and four men; their median age at onset was 59 years. The irAEs included Guillain-Barre syndrome (n = 5) and myasthenia gravis (MG) crisis with myositis (n = 4), and developed after a median of one (range 1-5) ICI cycle. The median modified Rankin score (mRS) was 4 (range 3-5) at the nadir. ICIs were discontinued in all patients, and rescue immunotherapy included corticosteroids (n = 9), intravenous immunoglobulin (n = 7), and plasmapheresis (n = 2). Eight patients showed improvements, with a median mRS of 3 (range 1-4); however, one patient (who had MG crisis with myocarditis) died. CONCLUSIONS In this real-world monocentric study, ICI-induced neuromuscular irAEs were rare but potentially devastating; thus, physicians should remain vigilant to enable prompt recognition and management of irAEs.
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Affiliation(s)
- Jae-Won Hyun
- Department of Neurology, Research Institute and Hospital of National Cancer Center, 323 Ilsan-Ro, Ilsandong-gu, Goyang, Korea.
| | - Ki Hoon Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, 323 Ilsan-Ro, Ilsandong-gu, Goyang, Korea
| | - Su-Hyun Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, 323 Ilsan-Ro, Ilsandong-gu, Goyang, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, 323 Ilsan-Ro, Ilsandong-gu, Goyang, Korea
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Quirynen R, Ocak S, Duplaquet F, Pirard L. Long-term complete remission after severe pembrolizumab-induced immune-related encephalitis in metastatic lung adeno-squamous carcinoma: A case report. Respir Med Case Rep 2023; 45:101898. [PMID: 37577125 PMCID: PMC10413185 DOI: 10.1016/j.rmcr.2023.101898] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Immune checkpoint inhibitors became the treatment of choice, in monotherapy or in association with platinum-based doublet chemotherapy, in first-line therapy for advanced-stage non-small-cell lung cancer without oncogenic driver. Nevertheless, it can be associated with diverse immune-related adverse events; several immune-related adverse events can also follow each other involving multiple organ systems, leading to immune checkpoint inhibitors discontinuation and immunosuppressive therapy that could compromise the prognosis of patients, with the exception of rare situations such as this clinical case. This case report illustrates a succession of immune-related adverse events including a rare and severe pembrolizumab-induced immune-related encephalitis in a patient with metastatic lung adeno-squamous carcinoma in whom we could observe a long-term and complete remission despite discontinuation of treatment and high-dose corticosteroids. In metastatic non-small-cell lung cancer, a disease with a poor initial prognosis, some patients can benefit from immune checkpoint inhibitors and can even now present a long-term and complete remission and this despite severe and rare immune-related adverse events, high-dose corticosteroids and an early discontinuation of treatment.
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Affiliation(s)
- Rémy Quirynen
- Department of Pulmonology, CHU UCL Namur (Godinne Site), Avenue Docteur Gaston Thérasse 1, 5530, Yvoir, Belgium
| | - Sebahat Ocak
- Department of Pulmonology, CHU UCL Namur (Godinne Site), Avenue Docteur Gaston Thérasse 1, 5530, Yvoir, Belgium
- Pole of Pulmonology, Institut de Recherche Expérimentale et Clinique UCL, Avenue Hippocrate 55, 1200, Woluwe-Saint-Lambert, Belgium
| | - Fabrice Duplaquet
- Department of Pulmonology, CHU UCL Namur (Godinne Site), Avenue Docteur Gaston Thérasse 1, 5530, Yvoir, Belgium
| | - Lionel Pirard
- Department of Pulmonology, CHU UCL Namur (Godinne Site), Avenue Docteur Gaston Thérasse 1, 5530, Yvoir, Belgium
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Farina A, Birzu C, Elsensohn MH, Picca A, Muñiz-Castrillo S, Vogrig A, Villagrán-García M, Ciano-Petersen NL, Massacesi L, Hervier B, Guégan S, Kramkimel N, Vano Y, Salem JE, Allenbach Y, Maisonobe T, Assaad S, Maureille A, Devic P, Weiss N, Pegat A, Maucort-Boulch D, Ricard D, Honnorat J, Psimaras D, Joubert B. Neurological outcomes in immune checkpoint inhibitor-related neurotoxicity. Brain Commun 2023; 5:fcad169. [PMID: 37389303 PMCID: PMC10306160 DOI: 10.1093/braincomms/fcad169] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 04/03/2023] [Accepted: 05/25/2023] [Indexed: 07/01/2023] Open
Abstract
While the spectrum of neurological immune checkpoint inhibitor-related adverse events is expanding, patients' outcomes are not well documented. This study aimed to assess outcomes of neurological immune-related adverse events and to identify prognostic factors. All patients experiencing grade ≥2 neurological immune-related adverse events identified at two clinical networks (French Reference Center for Paraneoplastic Neurological Syndromes, Lyon; and OncoNeuroTox, Paris) over five years were included. Modified Rankin scores were assessed at onset, 6, 12, 18 months, and last visit. A multi-state Markov model was used to estimate the transition rates between minor disability (mRS <3), severe disability (mRS 3-5), and death (mRS 6), over the study period. The state-to-state transition rates were estimated using maximum likelihood and variables were introduced into the different transitions to study their effects. A total of 147 patients were included out of 205 patients with a suspicion of neurological immune-related adverse events. The median age was 65 years (range 20-87) and 87/147 patients (59.2%) were male. Neurological immune-related adverse events involved the peripheral nervous system in 87/147 patients (59.2%), the central nervous system in 51/147 (34.7%), and both systems in 9/147 (6.1%). Paraneoplastic-like syndromes were observed in 30/147 patients (20.4%). Cancers included lung cancers (36.1%), melanoma (30.6%), urological cancers (15.6%), and others (17.8%). Patients were treated with programmed cell death protein (ligan) 1 (PD(L)1) inhibitors (70.1%), CTLA4 inhibitors (3.4%) or both (25.9%). Severe disability was reported in 108/144 patients (75.0%) at onset and in 33/146 patients (22.6%) at last visit (median follow-up duration: 12 months, range 0.5-50); 48/147 (32.7%) patients died, from cancer progression (17/48, 35.4%), neurological toxicity (15/48, 31.2%), other causes (10/48, 20.8%) or unknown causes (6/48, 12.5%). The rate of transition from severe to minor disability independently increased with melanoma [compared to lung cancer, hazard ratio = 3.26, 95%CI (1.27; 8.41)] and myositis/neuromuscular junction disorders [hazard ratio = 8.26, 95%CI (2.90; 23.58)], and decreased with older age [hazard ratio = 0.68, 95%CI (0.47; 0.99)] and paraneoplastic-like syndromes [hazard ratio = 0.29, 95%CI (0.09; 0.98)]. In patients with neurological immune-related adverse events, myositis/neuromuscular junction disorders and melanoma increase the transition rate from severe to minor disability, while older age and paraneoplastic-like syndromes result in poorer neurological outcomes; future studies are needed to optimize the management of such patients.
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Affiliation(s)
- Antonio Farina
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
- Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence 50139, Italy
| | - Cristina Birzu
- Department of Neurology 2 Mazarin, Sorbonne University, Brain Institute, INSERM UMR 1127, Groupe Hospitalier Pitié-Salpêtrière, Paris 75013, France
- OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments Groupe Hospitalier Pitié-Salpêtrière et Hôpital Percy, Paris 75561, France
| | | | | | - Sergio Muñiz-Castrillo
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
| | - Alberto Vogrig
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
| | - Macarena Villagrán-García
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
| | - Nicolás Lundahl Ciano-Petersen
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
| | - Luca Massacesi
- Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence 50139, Italy
| | - Baptiste Hervier
- Department of Internal Medicine, AP-HP, Hôpital St Louis, Paris 75010, France
| | - Sarah Guégan
- Department of Dermatology, AP-HP, Hôpital Cochin, Paris 75014, France
- Department of Dermatology, Université de Paris Cité, Paris 75006, France
| | - Nora Kramkimel
- Department of Dermatology, AP-HP, Hôpital Cochin, Paris 75014, France
| | - Yann Vano
- Department of Medical Oncology, AP-HP, Centre Hôpital Européen Georges-Pompidou, Paris 75015, France
| | - Joe Elie Salem
- Department of Pharmacology, Sorbonne University, INSERM, UNICO-GRECO Cardio-oncology Program, CIC-1901, AP-HP, Hôpital Pitié-Salpêtrière, F-75013 Paris, France
| | - Yves Allenbach
- APHP, Department of Internal Medicine, Sorbonne University, Sorbonne University, INSERM Groupe Hospitalier Pitié-Salpêtrière, Paris 75651, France
| | - Thierry Maisonobe
- APHP, Department of Clinical Neurophysiology, Sorbonne University, Paris 75013, France
| | - Souad Assaad
- Department of Medical Oncology, Léon Bérard Cancer Center, Lyon 69008, France
| | - Aurélien Maureille
- Department of Medical Oncology, Léon Bérard Cancer Center, Lyon 69008, France
| | - Perrine Devic
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, 69002 Lyon, France
- Department of Neurology, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon 69495, France
| | - Nicolas Weiss
- Department of Neurology, Sorbonne University, Hôpital de la Pitié-Salpêtrière, unité de Médecine Intensive Réanimation à orientation neurologique, Paris 75013, France
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Metabolic, Biliary and Fibro-Inflammatory Diseases of the Liver, Institute of Cardiometabolism and Nutrition (ICAN), Paris 75012, France
| | - Antoine Pegat
- Department of Neurological Functional Explorations, Hospices Civils de Lyon, Neurological Hospital, Bron 69500, France
| | - Delphine Maucort-Boulch
- Biostatistics—Bioinformatics Department, Public Health Unit. Hospices Civils de Lyon, Lyon 69003, France
- Laboratory of Biometry and Evolutionary Biology, University Claude Bernard Lyon 1, Villeurbanne 69622, France
- CNRS, UMR5558, Laboratory of Biometry and Evolutionary Biology, Biostatistics-Health Team, Villeurbanne 69622, France
| | - Damien Ricard
- OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments Groupe Hospitalier Pitié-Salpêtrière et Hôpital Percy, Paris 75561, France
- Neurology Department, Hôpital d’Instruction des Armées Percy, Service de Santé des Armées, Clamart 92140, France
| | - Jérôme Honnorat
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, 69002 Lyon, France
| | - Dimitri Psimaras
- Department of Neurology 2 Mazarin, Sorbonne University, Brain Institute, INSERM UMR 1127, Groupe Hospitalier Pitié-Salpêtrière, Paris 75013, France
- OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments Groupe Hospitalier Pitié-Salpêtrière et Hôpital Percy, Paris 75561, France
| | - Bastien Joubert
- Correspondence to: Bastien Joubert, MD, PhD French Reference Centre for Paraneoplastic Neurological Syndromes, Neurological Hospital 59 Boulevard Pinel, 69677 Bron Cedex, France E-mail:
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Chen YC, Jaffer M, Zhou L, Moslehi J, Forsyth PA, Fecher LA. A Brain, A Heart, and the Courage: Balancing Benefit and Toxicity of Immunotherapy in Melanoma. Am Soc Clin Oncol Educ Book 2023; 43:e390594. [PMID: 37229626 DOI: 10.1200/edbk_390594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The overall survival of advanced melanoma has improved dramatically. Immunotherapies, specifically checkpoint inhibitors, have played a large role in this improvement. These agents have also shown benefit in the adjuvant setting, are approved for treatment of resected stage II, III, and IV melanoma, and play an evolving role in the neoadjuvant setting. Although generally well tolerated, immune-related adverse events occur and can be severe. Here we focus on some severe and potentially long term toxicities, including cardiovascular and neurologic toxicities. Our understanding of the acute and long-term toxicities of immune checkpoint inhibitors continues to evolve. Oncologists must continue to balance cancer risk and treatment-related toxicities.
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Affiliation(s)
- Yen-Chou Chen
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
- Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Muhammad Jaffer
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
| | - Lylybell Zhou
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Javid Moslehi
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Peter A Forsyth
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
- Department of Oncology, Moffitt Cancer Center and University of South Florida, Tampa, FL
| | - Leslie A Fecher
- Rogel Cancer Center at the University of Michigan, Ann Arbor, MI
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Masi G, Pham MC, Karatz T, Oh S, Payne AS, Nowak RJ, Howard JF, Guptill JT, Juel VC, O'Connor KC. Clinicoserological insights into patients with immune checkpoint inhibitor-induced myasthenia gravis. Ann Clin Transl Neurol 2023; 10:825-831. [PMID: 36924454 PMCID: PMC10187728 DOI: 10.1002/acn3.51761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
To compare the immunopathology of immune checkpoint inhibitor-induced myasthenia gravis (ICI-MG) and idiopathic MG, we profiled the respective AChR autoantibody pathogenic properties. Of three ICI-MG patients with AChR autoantibodies, only one showed complement activation and modulation/blocking potency, resembling idiopathic MG. In contrast, AChR autoantibody-mediated effector functions were not detected in the other two patients, questioning the role of their AChR autoantibodies as key mediators of pathology. The contrasting properties of AChR autoantibodies in these cases challenge the accuracy of serological testing in establishing definite ICI-MG diagnoses and underscore the importance of a thorough clinical assessment when evaluating ICI-related adverse events.
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Affiliation(s)
- Gianvito Masi
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - Minh C Pham
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - Tabitha Karatz
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Sangwook Oh
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
| | - Aimee S Payne
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - James F Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, CB#7025, Houpt Building, 170 Manning Drive, Chapel Hill, North Carolina, 27599-7025, USA
| | - Jeffrey T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Vern C Juel
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Kevin C O'Connor
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
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Claytor B, Cho SM, Li Y. Myasthenic crisis. Muscle Nerve 2023. [PMID: 37114503 DOI: 10.1002/mus.27832] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/06/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023]
Abstract
Myasthenic crisis (MC) is a life-threatening manifestation of myasthenia gravis (MG) defined by respiratory insufficiency that requires the use of invasive or non-invasive ventilation. This is often the result of respiratory muscle weakness but can also be due to bulbar weakness with upper airway collapse. MC occurs in approximately 15%-20% of patients with MG usually within the first 2 to 3 y of the disease course. Many crises have a specific trigger with respiratory infections being most common; however, no specific trigger is found in 30%-40% of patients. MG patients with a history of MC, severe disease, oropharyngeal weakness, muscle-specific kinase (MuSK) antibodies and thymoma appear to be at higher risk. Most episodes of MC do not occur suddenly, providing a window of opportunity for prevention. Immediate treatment is directed toward airway management and removing any identified triggers. Plasmapheresis is preferred over intravenous immune globulin as the treatments of choice for MC. The majority of patients are able to be weaned from mechanical ventilation within 1 mo and the outcomes of MC are generally favorable. The mortality rate in United States cohorts is less than 5% and mortality in MC seems to be driven by age and other medical co-morbidities. MC does not appear to affect long-term prognosis as many patients are able to eventually achieve good MG control.
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Affiliation(s)
- Benjamin Claytor
- Neuromuscular Center, Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuebing Li
- Neuromuscular Center, Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Bompaire F, Birzu C, Bihan K, Desestret V, Fargeot G, Farina A, Joubert B, Leclercq D, Nichelli L, Picca A, Tafani C, Weiss N, Psimaras D, Ricard D. Advances in treatments of patients with classical and emergent neurological toxicities of anticancer agents. Rev Neurol (Paris) 2023; 179:405-416. [PMID: 37059646 DOI: 10.1016/j.neurol.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 04/16/2023]
Abstract
The neurotoxicity associated to the anticancer treatments has received a growing body of interest in the recent years. The development of innovating therapies over the last 20years has led to the emergence of new toxicities. Their diagnosis and management can be challenging in the clinical practice and further research is warranted to improve the understanding of their pathogenic mechanisms. Conventional treatments as radiation therapy and chemotherapy are associated to well-known and under exploration emerging central nervous system (CNS) and peripheral nervous system (PNS) toxicities. The identification of the risk factors and a better understanding of their pathogeny through a "bench to bedside and back again" approach, are the first steps towards the development of toxicity mitigation strategies. New imaging techniques and biological explorations are invaluable for their diagnosis. Immunotherapies have changed the cancer treatment paradigm from tumor cell centered to immune modulation towards an efficient anticancer immune response. The use of the immune checkpoints inhibitors (ICI) and chimeric antigen receptor (CAR-T cells) lead to an increase in the incidence of immune-mediated toxicities and new challenges in the neurological patient's management. The neurological ICI-related adverse events (n-irAE) are rare but potentially severe and may present with both CNS and PNS involvement. The most frequent and well characterized, from a clinical and biological standpoint, are the PNS phenotypes: myositis and polyradiculoneuropathy, but the knowledge on CNS phenotypes and their treatments is expanding. The n-irAE management requires a good balance between dampening the autoimmune toxicity without impairing the anticancer immunity. The adoptive cell therapies as CAR-T cells, a promising anticancer strategy, trigger cellular activation and massive production of proinflammatory cytokines inducing frequent and sometime severe toxicity known as cytokine release syndrome and immune effector cell-associated neurologic syndrome. Their management requires a close partnership between oncologist-hematologists, neurologists, and intensivists. The oncological patient's management requires a multidisciplinary clinical team (oncologist, neurologist and paramedical) as well as a research team leading towards a better understanding and a better management of the neurological toxicities.
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Affiliation(s)
- Flavie Bompaire
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; UMR 9010 Centre Borelli, Université Paris-Saclay, École Normale Supérieure Paris-Saclay, CNRS, Service de Santé des Armées, Université Paris Cité, Inserm, Saclay, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France
| | - Cristina Birzu
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Kevin Bihan
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Pharmacologie, Centre Régional de Pharmacovigilance, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Inserm, CIC-1901, Sorbonne Universités, Paris, France
| | - Virginie Desestret
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Service de Neurocognition et Neuro-ophtalmologie, Hospices Civils de Lyon, Hôpital Neurologique Pierre-Wertheimer, Lyon, France; Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France
| | - Guillaume Fargeot
- AP-HP, Service de Neurologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Antonio Farina
- Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Service de Neurologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Bastien Joubert
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Service de Neurologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Delphine Leclercq
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Neuroradiologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France
| | - Lucia Nichelli
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Neuroradiologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France
| | - Alberto Picca
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Camille Tafani
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France
| | - Nicolas Weiss
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino. Università di Firenze, Firenze, Italy; AP-HP, Service de Soins Intensifs en Neurologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France; École du Val-de-Grâce, Service de Santé des Armées, Paris, France
| | - Dimitri Psimaras
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Damien Ricard
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; UMR 9010 Centre Borelli, Université Paris-Saclay, École Normale Supérieure Paris-Saclay, CNRS, Service de Santé des Armées, Université Paris Cité, Inserm, Saclay, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; École du Val-de-Grâce, Service de Santé des Armées, Paris, France.
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Miske R, Scharf M, Borowski K, Rieckhoff N, Teegen B, Denno Y, Probst C, Guthke K, Didrihsone I, Wildemann B, Ruprecht K, Komorowski L, Jarius S. Septin-3 autoimmunity in patients with paraneoplastic cerebellar ataxia. J Neuroinflammation 2023; 20:88. [PMID: 36997937 PMCID: PMC10061979 DOI: 10.1186/s12974-023-02718-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/03/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Septins are cytoskeletal proteins with filament forming capabilities, which have multiple roles during cell division, cellular polarization, morphogenesis, and membrane trafficking. Autoantibodies against septin-5 are associated with non-paraneoplastic cerebellar ataxia, and autoantibodies against septin-7 with encephalopathy with prominent neuropsychiatric features. Here, we report on newly identified autoantibodies against septin-3 in patients with paraneoplastic cerebellar ataxia. We also propose a strategy for anti-septin autoantibody determination. METHODS Sera from three patients producing similar immunofluorescence staining patterns on cerebellar and hippocampal sections were subjected to immunoprecipitation followed by mass spectrometry. The identified candidate antigens, all of which were septins, were expressed recombinantly in HEK293 cells either individually, as complexes, or combinations missing individual septins, for use in recombinant cell-based indirect immunofluorescence assays (RC-IIFA). Specificity for septin-3 was further confirmed by tissue IIFA neutralization experiments. Finally, tumor tissue sections were analyzed immunohistochemically for septin-3 expression. RESULTS Immunoprecipitation with rat cerebellum lysate revealed septin-3, -5, -6, -7, and -11 as candidate target antigens. Sera of all three patients reacted with recombinant cells co-expressing septin-3/5/6/7/11, while none of 149 healthy control sera was similarly reactive. In RC-IIFAs the patient sera recognized only cells expressing septin-3, individually and in complexes. Incubation of patient sera with five different septin combinations, each missing one of the five septins, confirmed the autoantibodies' specificity for septin-3. The tissue IIFA reactivity of patient serum was abolished by pre-incubation with HEK293 cell lysates overexpressing the septin-3/5/6/7/11 complex or septin-3 alone, but not with HEK293 cell lysates overexpressing septin-5 as control. All three patients had cancers (2 × melanoma, 1 × small cell lung cancer), presented with progressive cerebellar syndromes, and responded poorly to immunotherapy. Expression of septin-3 was demonstrated in resected tumor tissue available from one patient. CONCLUSIONS Septin-3 is a novel autoantibody target in patients with paraneoplastic cerebellar syndromes. Based on our findings, RC-IIFA with HEK293 cells expressing the septin-3/5/6/7/11 complex may serve as a screening tool to investigate anti-septin autoantibodies in serological samples with a characteristic staining pattern on neuronal tissue sections. Autoantibodies against individual septins can then be confirmed by RC-IIFA expressing single septins.
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Affiliation(s)
- Ramona Miske
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Madeleine Scharf
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany.
| | - Kathrin Borowski
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Lübeck, Germany
| | - Nicole Rieckhoff
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Bianca Teegen
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Lübeck, Germany
| | - Yvonne Denno
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Kersten Guthke
- Department of Neurology, Städtisches Klinikum Görlitz, Görlitz, Germany
| | - Ieva Didrihsone
- Department of Neurology, Hermann-Josef-Krankenhaus, Erkelenz, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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Tezuka T, Okuzumi S, Nakashima C, Ide T, Imai S, Mitsuboshi S, Kuwahara Y, Takizawa T, Seki M, Minematsu N, Aragane N, Nakahara J, Hori S, Nakane S, Suzuki S. Dysautonomia associated with immune checkpoint inhibitors. J Neurol 2023:10.1007/s00415-023-11667-5. [PMID: 36939931 DOI: 10.1007/s00415-023-11667-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/15/2023] [Accepted: 03/14/2023] [Indexed: 03/21/2023]
Abstract
OBJECTIVE The purpose of this study is to report the clinical characteristics of dysautonomia associated with immune checkpoint inhibitors (ICIs). METHODS We reported two patients with autoimmune autonomic ganglionopathy (AAG) occurring as immune-related adverse events (irAEs). We also performed a review of previous case reports presenting dysautonomia during ICI therapy. Moreover, we conducted pharmacovigilance analyses using the US Food and Drug Administration Adverse Events Reporting System (FAERS) to investigate dysautonomia associated with ICI. RESULTS Two patients in our care developed both AAG and autoimmune encephalitis following ICI therapy for lung cancers. We comprehensively reviewed 13 published cases (M:F = 11:2, mean onset age of 53 years) with ICI-associated dysautonomia including AAG (n = 3) and autonomic neuropathy (n = 10). Of these, ICI monotherapy was performed in seven and combination ICI use in six. In 6 of 13 patients, dysautonomia appeared within one month after the start of ICIs. Orthostatic hypotension was observed in 7 and urinary incontinence or retention in five. All patients except three showed gastrointestinal symptoms. Anti-ganglionic acetylcholine receptor antibodies were undetectable. All but two patients received immune-modulating therapy. Immuno-modulating therapy was effective in three patients with AAG and two patients with autonomic neuropathy, but ineffective in the others. Five patients died, of either the neurological irAE (n = 3) or cancer (n = 2). The pharmacovigilance analyses using FAERS showed that ipilimumab monotherapy and the combination of nivolumab and ipilimumab constituted significant risks for developing dysautonomia, consistent with the review of literature. CONCLUSION ICIs can cause dysautonomia including AAG, and autonomic neuropathy is a neurological irAE.
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Affiliation(s)
- Toshiki Tezuka
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Shinichi Okuzumi
- Department of Internal Medicine, Hino Municipal Hospital, Tokyo, Japan
| | - Chiho Nakashima
- Division of Haematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Toshihiro Ide
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shungo Imai
- Division of Drug Informatics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Satoru Mitsuboshi
- Division of Drug Informatics, Faculty of Pharmacy, Keio University, Tokyo, Japan.,Department of Pharmacy, Kaetsu Hospital, Niigata, Japan
| | - Yuki Kuwahara
- Division of Haematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Morinobu Seki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Naoto Minematsu
- Department of Internal Medicine, Hino Municipal Hospital, Tokyo, Japan
| | - Naoko Aragane
- Division of Haematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Satoko Hori
- Division of Drug Informatics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Shunya Nakane
- Department of Neurology, Nippon Medical University, Tokyo, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan.
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Farina A, Villagrán-García M, Honnorat J. Neurological adverse events of immune checkpoint inhibitors: An update of clinical presentations, diagnosis, and management. Rev Neurol (Paris) 2023; 179:506-515. [PMID: 36934022 DOI: 10.1016/j.neurol.2023.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023]
Abstract
The use of immune checkpoint inhibitors (ICIs) has represented a major advance in cancer treatment. By enhancing endogenous immune responses to destroy cancer cells, ICIs can cause immune-related adverse events (irAEs), with possible involvement of any organ system. IrAEs are frequent, particularly those involving the skin or the endocrine system, and usually completely reversible after temporary immunosuppression, while neurological irAEs (n-irAEs) are relatively rare, often severe, and they carry a considerable risk of mortality and long-term disability. They usually affect the peripheral nervous system, mainly manifesting as myositis, polyradiculoneuropathy, or cranial neuropathy, and, less frequently, involve the central nervous system, causing encephalitis, meningitis, or myelitis. Although somehow reminiscent of the disorders that neurologists are familiar to deal with in their daily practice, n-irAEs are characterized by distinctive features from their idiopathic counterparts; for instance, myositis may have a predominant oculo-bulbar involvement reminiscent of myasthenia gravis and frequently associates with myocarditis; peripheral neuropathy, although often resembling Guillain-Barré syndrome, usually responds to corticosteroids. Remarkably, several associations between the neurological phenotype and the type of ICIs or the type of cancer have emerged in the last few years, and the growing administration of ICIs in patients with neuroendocrine cancers has led to an increased number of reports of paraneoplastic neurological syndromes (triggered or worsened by ICIs). This review aims to update current knowledge regarding the clinical presentation of n-irAEs. We also discuss the essential parts of the diagnostic approach, and we provide general recommendations for the management of these disorders.
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Affiliation(s)
- A Farina
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino, Università di Firenze, Firenze, Italy
| | - M Villagrán-García
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France
| | - J Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France.
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Evaluation and management of acute high-grade immunotherapy-related neurotoxicity. Heliyon 2023; 9:e13725. [PMID: 36851967 PMCID: PMC9958505 DOI: 10.1016/j.heliyon.2023.e13725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Immune checkpoint inhibitor monoclonal antibodies allow the host's immune system to attack tumors, which has revolutionized cancer care over the last decade. As the use of immune checkpoint inhibitors has expanded, so have autoimmune-like complications known as immune-related adverse events. These include the infrequent but increasingly more common, potentially deadly neurological immune related adverse events. When feeling acutely ill, patients will often seek care not from their oncologist but from their family physician, clinics, emergency, and urgent care sites, or other available providers. Thus, while assessing acutely ill cancer patients who are experiencing neurological symptoms, non-oncologists should be prepared to recognize, diagnose, and treat neurological immune related adverse events in addition to more familiar conditions. This narrative review is designed to update acute care clinicians on current knowledge and to present a symptom-based framework for evaluating and treating neurological immune related adverse events based on the leading immunotoxicity organizations' latest recommendations.
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50
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Abstract
PURPOSE OF REVIEW To provide an overview and highlight recent updates in the field of paraneoplastic neurologic disorders. RECENT FINDINGS The prevalence of paraneoplastic neurologic disorders is greater than previously reported and the incidence has been rising over time, due to improved recognition in the era of antibody biomarkers. Updated diagnostic criteria that are broadly inclusive and also contain diagnostic risk for clinical presentations (high and intermediate) and diagnostic antibodies (high, intermediate, and low) have replaced the original 2004 criteria. Antibody biomarkers continue to be characterized (e.g., KLHL-11 associated with seminoma in men with brainstem encephalitis). Some paraneoplastic antibodies also provide insight into likely immunotherapy response and prognosis. The rise of immune checkpoint inhibitors as cancer therapeutics has been associated with newly observed immune-mediated adverse effects including paraneoplastic neurological disorders. The therapeutic approach to paraneoplastic neurologic disorders is centered around cancer care and trials of immune therapy. The field of paraneoplastic neurologic disorders continues to be advanced by the identification of novel antibody biomarkers which have diagnostic utility, and give insight into likely treatment responses and outcomes.
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Affiliation(s)
- Michael Gilligan
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA.
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55905, USA.
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