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Hong N, Wang B, Zhou HC, Wu ZX, Fang HY, Song GQ, Yu Y. Multidisciplinary management of ulcerative colitis complicated by immune checkpoint inhibitor-associated colitis with life-threatening gastrointestinal hemorrhage: A case report. World J Gastrointest Surg 2024; 16:2329-2336. [PMID: 39087117 PMCID: PMC11287687 DOI: 10.4240/wjgs.v16.i7.2329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 05/26/2024] [Accepted: 06/18/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Programmed cell death 1 (PD-1) inhibitors are immune checkpoint inhibitors (ICI) that have demonstrated significant efficacy in treating various advanced malignant tumors. While most patients tolerate treatment well, several adverse drug reactions, such as fatigue, myelosuppression, and ICI-associated colitis, have been reported. CASE SUMMARY This case involved a 57-year-old male patient with ulcerative colitis complicated by hepatocarcinoma who underwent treatment with tirelizumab (a PD-1 inhibitor) for six months. The treatment led to repeated life-threatening lower gastrointestinal hemorrhage. The patient received infliximab, vedolizumab, and other salvage procedures but ultimately required subtotal colectomy due to uncontrollable massive lower gastrointestinal bleeding. Currently, postoperative gastrointestinal bleeding has stopped, the patient's stool has turned yellow, and his full blood cell count has returned to normal. CONCLUSION This case highlights the necessity of early identification, timely and adequate treatment of ICI-related colitis, and rapid escalation to achieve the goal of improving prognosis.
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Affiliation(s)
- Na Hong
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Bo Wang
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Hang-Cheng Zhou
- Department of Pathology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230036, Anhui Province, China
- Intelligent Pathology Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230036, Anhui Province, China
| | - Zheng-Xiang Wu
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Hua-Ying Fang
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Geng-Qing Song
- Department of Gastroenterology and Hepatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH 44109, United States
| | - Yue Yu
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
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Chen YH, Kovács T, Ferdinandy P, Varga ZV. Treatment options for immune-related adverse events associated with immune checkpoint inhibitors. Br J Pharmacol 2024. [PMID: 38803135 DOI: 10.1111/bph.16405] [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: 12/01/2023] [Revised: 02/14/2024] [Accepted: 03/09/2024] [Indexed: 05/29/2024] Open
Abstract
The immunotherapy revolution with the use of immune checkpoint inhibitors (ICIs) started with the clinical use of the first ICI, ipilimumab, in 2011. Since then, the field of ICI therapy has rapidly expanded - with the FDA approval of 10 different ICI drugs so far and their incorporation into the therapeutic regimens of a range of malignancies. While ICIs have shown high anti-cancer efficacy, they also have characteristic side effects, termed immune-related adverse events (irAEs). These side effects hinder the therapeutic potential of ICIs and, therefore, finding ways to prevent and treat them is of paramount importance. The current protocols to manage irAEs follow an empirical route of steroid administration and, in more severe cases, ICI withdrawal. However, this approach is not optimal in many cases, as there are often steroid-refractory irAEs, and there is a potential for corticosteroid use to promote tumour progression. This review surveys the current alternative approaches to the treatments for irAEs, with the goal of summarizing and highlighting the best attempts to treat irAEs, without compromising anti-tumour immunity and allowing for rechallenge with ICIs after resolution of the irAEs.
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Affiliation(s)
- Yu Hua Chen
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Tamás Kovács
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Zoltán V Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
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Velikova T, Krastev B, Gulinac M, Zashev M, Graklanov V, Peruhova M. New strategies in the diagnosis and treatment of immune-checkpoint inhibitor-mediated colitis. World J Clin Cases 2024; 12:1050-1062. [PMID: 38464930 PMCID: PMC10921308 DOI: 10.12998/wjcc.v12.i6.1050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 02/20/2024] Open
Abstract
Immune-checkpoint inhibitor-mediated colitis (IMC) is an increasingly recognized adverse event in cancer immunotherapy, particularly associated with immune checkpoint inhibitors (ICIs) such as anti-cytotoxic T-lymphocyte antigen-4 and anti-programmed cell death protein-1 antibodies. As this revolutionary immunotherapy gains prominence in cancer treatment, understanding, diagnosing, and effectively managing IMC becomes paramount. IMC represents a unique challenge due to its immune-mediated nature and potential for severe complications. However, a precise picture of IMC pathophysiology is currently unavailable. Therefore, we aimed to summarize the existing data while acknowledging the need for further research. This comprehensive review explores the mechanisms underlying ICIs, gastrointestinal adverse effects, and, in particular, IMC's incidence, prevalence, and features. Our review also emphasizes the importance of recognizing IMC's distinct clinical and histopathological features to differentiate it from other forms of colitis. Furthermore, this paper highlights the urgent need for evolving diagnostic methods, therapeutic strategies, and a multidisciplinary approach to effectively manage IMC.
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Affiliation(s)
- Tsvetelina Velikova
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
| | - Boris Krastev
- Medical Center Nadezhda, Medical Center Nadezhda, Sofia 1407, Bulgaria
| | - Milena Gulinac
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
- General and Clinical Pathology, Medical University of Plovdiv, Plovdiv 4002, Bulgaria
| | - Miroslav Zashev
- Department of General Surgery, University Hospital “Heart and Brain”, Burgas 8000, Bulgaria
| | - Vasko Graklanov
- First Department of Internal Diseases, Medical University of Plovdiv, Plovdiv 4000, Bulgaria
- Department of Hematology, University Hospital “St. George”, Plovdiv 4000, Bulgaria
| | - Milena Peruhova
- Division of Gastroenterology, University Hospital “Heart and Brain”, Burgas 1000, Bulgaria
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4
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Christyani G, Carswell M, Qin S, Kim W. An Overview of Advances in Rare Cancer Diagnosis and Treatment. Int J Mol Sci 2024; 25:1201. [PMID: 38256274 PMCID: PMC10815984 DOI: 10.3390/ijms25021201] [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: 12/01/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open
Abstract
Cancer stands as the leading global cause of mortality, with rare cancer comprising 230 distinct subtypes characterized by infrequent incidence. Despite the inherent challenges in addressing the diagnosis and treatment of rare cancers due to their low occurrence rates, several biomedical breakthroughs have led to significant advancement in both areas. This review provides a comprehensive overview of state-of-the-art diagnostic techniques that encompass new-generation sequencing and multi-omics, coupled with the integration of artificial intelligence and machine learning, that have revolutionized rare cancer diagnosis. In addition, this review highlights the latest innovations in rare cancer therapeutic options, comprising immunotherapy, targeted therapy, transplantation, and drug combination therapy, that have undergone clinical trials and significantly contribute to the tumor remission and overall survival of rare cancer patients. In this review, we summarize recent breakthroughs and insights in the understanding of rare cancer pathophysiology, diagnosis, and therapeutic modalities, as well as the challenges faced in the development of rare cancer diagnosis data interpretation and drug development.
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Affiliation(s)
| | | | - Sisi Qin
- Department of Integrated Biomedical Science, Soonchunhyang Institute of Medi-Bio Science (SIMS), Soonchunhyang University, Cheonan 31151, Chungcheongnam-do, Republic of Korea; (G.C.); (M.C.)
| | - Wootae Kim
- Department of Integrated Biomedical Science, Soonchunhyang Institute of Medi-Bio Science (SIMS), Soonchunhyang University, Cheonan 31151, Chungcheongnam-do, Republic of Korea; (G.C.); (M.C.)
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Gómez Escudero O. Enterocolitis and other immunotherapy and targeted therapy-related gastrointestinal manifestations: A review for gastroenterologist. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:89-105. [PMID: 38485558 DOI: 10.1016/j.rgmxen.2023.11.001] [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: 07/21/2023] [Accepted: 11/08/2023] [Indexed: 04/20/2024]
Abstract
New oncologic treatments, particularly immunotherapy (IT), have revolutionized the treatment of advanced-stage malignant tumors. Immune checkpoint inhibitors are the main form of IT and act by increasing T cell activity and the organism's immune response against neoplastic cells. Targeted therapy is another form of IT that acts by inhibiting oncogenes or inflammation signaling and tumor angiogenesis pathways. However, these mechanisms of tumor destruction can interfere with the host's immune self-tolerance or with the mechanisms of epithelial tissue repair and predispose to immune system-mediated adverse events that can affect multiple organs, including the digestive tract. The gastrointestinal manifestations of damage caused by IT can range from low-grade mucositis to ulceration, and in some cases, necrosis and perforation. Any part of the gastrointestinal tract can be affected, but there is greater involvement of the small bowel and colon, with a pattern similar to that seen in inflammatory bowel disease. The most common clinical manifestation is chronic diarrhea. The differential diagnosis includes enteropathogenic infections, especially those caused by opportunistic microorganisms; adverse drug reactions; and other inflammatory and malabsorption disorders. Treatment is guided by damage severity. Mild cases can be treated with antidiarrheals and rehydration in the outpatient setting; moderate cases with hospitalization, systemic steroids, and temporary suspension of IT; and severe cases with immunosuppressants or biologic agents and definitive suspension of IT.
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Affiliation(s)
- O Gómez Escudero
- Clínica de Gastroenterología, Endoscopia Digestiva y Motilidad Gastrointestinal «Endoneurogastro», Hospital Ángeles, Puebla, Mexico.
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Céspedes Martínez E, Robles Alonso V, Herrera-De Guise C, Mayorga L, Casellas F, Roca-Herrera M, Borruel N. Severe and refractory gastrointestinal toxicity due to immune checkpoint inhibitors: clinical experience in a tertiary referral hospital. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:567-573. [PMID: 37170542 DOI: 10.17235/reed.2023.9436/2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
INTRODUCTION immune checkpoint inhibitors (ICI) are increasingly used to treat several types of cancer. These drugs lead to a wide range of toxicities. Immune-related gastrointestinal adverse events are common and potentially severe. In this manuscript, we recount the real clinical experience in a tertiary center. METHODS a retrospective and observational study was conducted in adult patients under ICI treatment. Included patients had been referred to the Gastrointestinal Service of Hospital Universitario Vall d'Hebron for evaluation of severe toxicities, from January 2017 to January 2020, for whom the clinical, epidemiological and evolutive data were collected. RESULTS a total of 18 patients were included. Fifty-five percent received anti-programmed cell death protein 1 (PD-1)/anti-programmed death-ligand 1 (anti PD-L1), 11 % received anti-cytotoxic T lymphocyte antigen 4 (CTLA-4) and 33 % received both treatments. The toxicities were manifested as enterocolitis, microscopic colitis and gastritis. Upper gastrointestinal endoscopy was performed in seven patients; all were proved to have histological changes on duodenum biopsies. Treatment was stopped in all patients and steroids were initiated. Sixty-six per cent achieved clinical remission with steroids. Five patients received anti-TNF treatment (infliximab). Only one of the five had responded. Two anti-TNF refractory patients received ustekinumab, with an appropriate clinical response. One patient received apheresis granulocyte as concomitant treatment. A patient with a steroid-dependent course started vedolizumab. Three patients had other immune-related adverse events. CONCLUSION gastrointestinal immune-related adverse events are acquiring a higher profile in daily practice and gastroenterologists play an even greater role in the management of these patients.
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Affiliation(s)
| | | | | | - Luis Mayorga
- Gastroenterology, Hospital Universitari Vall d'Hebron, España
| | | | | | - Natalia Borruel
- Gastroenterology, Hospital Universitari Vall d'Hebron, España
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7
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Tang L, Huang Z, Mei H, Hu Y. Immunotherapy in hematologic malignancies: achievements, challenges and future prospects. Signal Transduct Target Ther 2023; 8:306. [PMID: 37591844 PMCID: PMC10435569 DOI: 10.1038/s41392-023-01521-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 08/19/2023] Open
Abstract
The immune-cell origin of hematologic malignancies provides a unique avenue for the understanding of both the mechanisms of immune responsiveness and immune escape, which has accelerated the progress of immunotherapy. Several categories of immunotherapies have been developed and are being further evaluated in clinical trials for the treatment of blood cancers, including stem cell transplantation, immune checkpoint inhibitors, antigen-targeted antibodies, antibody-drug conjugates, tumor vaccines, and adoptive cell therapies. These immunotherapies have shown the potential to induce long-term remission in refractory or relapsed patients and have led to a paradigm shift in cancer treatment with great clinical success. Different immunotherapeutic approaches have their advantages but also shortcomings that need to be addressed. To provide clinicians with timely information on these revolutionary therapeutic approaches, the comprehensive review provides historical perspectives on the applications and clinical considerations of the immunotherapy. Here, we first outline the recent advances that have been made in the understanding of the various categories of immunotherapies in the treatment of hematologic malignancies. We further discuss the specific mechanisms of action, summarize the clinical trials and outcomes of immunotherapies in hematologic malignancies, as well as the adverse effects and toxicity management and then provide novel insights into challenges and future directions.
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Affiliation(s)
- Lu Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, 430022, Wuhan, China
- Key Laboratory of Biological Targeted Therapy, the Ministry of Education, 430022, Wuhan, China
| | - Zhongpei Huang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, 430022, Wuhan, China
- Key Laboratory of Biological Targeted Therapy, the Ministry of Education, 430022, Wuhan, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, 430022, Wuhan, China.
- Key Laboratory of Biological Targeted Therapy, the Ministry of Education, 430022, Wuhan, China.
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, 430022, Wuhan, China.
- Key Laboratory of Biological Targeted Therapy, the Ministry of Education, 430022, Wuhan, China.
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
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Li C, Wang L, Sun D, Yao T, Xian X, Cheng Y. Colitis induced by PD-1 inhibitor combined with platinum-containing dual drug chemotherapy in Lewis mice and its mechanism. J Cancer Res Ther 2023; 19:939-944. [PMID: 37675720 DOI: 10.4103/jcrt.jcrt_2078_22] [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] [Indexed: 09/08/2023]
Abstract
Aims To explore the occurrence and possible mechanism of colitis in Lewis mice treated with PD-1 inhibitor combined with platinum-containing dual drug chemotherapy. Subjects and Methods A Lewis lung cancer model of C57BL/6 mice was established, randomly divided into the treatment group (group C, PD-1 inhibitor + Carboplatin (CARB) + Pemetrexed (PEM)) and model group (group B, normal saline), and a control group (group A, normal saline) was set up. Observe the changes in tumor-free weight, tumor volume, disease activity index (DAI), colon histopathology, identify serum interleukin (IL)-10, interferon (IFN)-γ, the expression of claudin-1, and occludin mRNA in the colon in each animals. Results Compared with group A, the tumor-free weight of mice in B decreased (P < 0.001), the content of IL-10 in serum increased (P < 0.01), the content of IFN-γ in serum decreased (P < 0.01). Compared with group B, the transplanted tumor volume in C was reduced (P < 0.05), DAI scores of D4 (P < 0.001), and D7 (P < 0.001) were increased, colonic histopathology analysis showed that colitis occurred, serum IL-10 content was decreased (P < 0.05), IFN-γ content was increased (P < 0.05), and the mRNA expression of claudin-1 (P < 0.05) and occludin (P < 0.05) was reduced. Conclusions This treatment can inhibit the growth of transplanted tumors but will cause colitis in Lewis mice. The impairment of intestinal barrier function following administration cause an imbalance in the expression of pro-inflammatory and anti-inflammatory factors in the colon, thus causing colitis.
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Affiliation(s)
- Chunhai Li
- Department of Radiology, The Qilu Hospital of Shandong University, Jinan Shandong, China
| | - Lixin Wang
- Department of School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong, China
| | - Daqian Sun
- Department of Radiology, The Qilu Hospital of Shandong University, Jinan Shandong, China
| | - Tianxiao Yao
- Department of Radiology, The Qilu Hospital of Shandong University, Jinan Shandong, China
| | - Xiuying Xian
- Department of Interventional Department, Jinan Central Hospital, Jinan Shandong, China
| | - Yufeng Cheng
- Department of Radiotherapy, The Qilu Hospital of Shandong University, Jinan, Shandong, China
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Faleck DM, Dougan M, Tello M, Grossman JE, Moss AC, Postow MA. Accelerating the Evolution of Immune-Related Enterocolitis Management. J Clin Oncol 2023; 41:3110-3115. [PMID: 37040601 PMCID: PMC10256374 DOI: 10.1200/jco.22.02914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/14/2023] [Accepted: 03/09/2023] [Indexed: 04/13/2023] Open
Affiliation(s)
- David M. Faleck
- Gastroenterology, Hepatology & Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Michael Dougan
- Division of Gastroenterology and Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | | | | | - Alan C. Moss
- Division of Gastroenterology, Department of Medicine, Boston Medical Center, Boston, MA
| | - Michael A. Postow
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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10
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Braun DS, Patel S, Schwartz A. Subclinical Celiac Disease Unmasked by Immune Checkpoint Inhibitor Therapy. J Immunother 2023; 46:152-153. [PMID: 36780126 DOI: 10.1097/cji.0000000000000452] [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: 11/03/2022] [Accepted: 01/12/2023] [Indexed: 02/14/2023]
Abstract
Immune checkpoint inhibitors (ICI) are antibodies that block immune checkpoint proteins from binding with their partner proteins on cancer cells, subsequently allowing cytotoxic T-cell-associated enhancement of antitumor responses. Although ICIs have become the standard of care for various malignancies, their use is often limited by unique immune-related adverse events, including dermatologic, endocrine, inflammatory, hepatic, and gastrointestinal events. Diarrhea and colitis are common lower gastrointestinal tract immune-related adverse events, however, only a few cases have reported the association between celiac disease (CD) and ICIs. We report here a case of a 75-year-old man with new onset CD after exposure to the cytotoxic T-lymphocyte-associated antigen-4 ICI, ipilimumab. Although ICI-induced CD is relatively rare, it is essential to consider it in a genetically susceptible patient undergoing treatment with ICI. Patients with known high susceptibility to CD, such as a family history of CD, or with the ancestry of high celiac penetrance (eg, Northern Europe, North Africa, etc), dermatitis herpetiformis, or chronic bowel symptoms, we feel should have celiac panel testing before initiating ICI therapy.
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Affiliation(s)
| | | | - Armond Schwartz
- Digestive Health Associates of Texas, Methodist Dallas Medical Center, Dallas, TX
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Zhang P, Mao R, Zhang C, Qiu Y, Chen M. Gastrointestinal injury induced by immunomodulators: A review article. Therap Adv Gastroenterol 2023; 16:17562848231158549. [PMID: 37113189 PMCID: PMC10126616 DOI: 10.1177/17562848231158549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 02/02/2023] [Indexed: 04/29/2023] Open
Abstract
An increasing number of immunomodulators, either anti-inflammatory or immunity-enhancing, have brought about a revolutionary effect in the management of a variety of autoimmune disorders and malignancies. However, their ability to cause gastrointestinal (GI) injury and induce GI symptoms has been increasingly and unexpectedly recognized. GI injury associated with immunomodulators may demonstrate various histologic and endoscopic patterns. Optimal diagnosis and treatment require a multidisciplinary approach. This review aims to provide an overview of the literature on its pathogenesis, the clinical, endoscopic, and histologic features, and suggested approaches to manage these newly recognized immunomodulator-induced GI adverse effects (AEs). We also reviewed current biomarkers predictive of GI toxicity and potential risk factors to identify susceptible patients. In addition, these immune-mediated AEs were compared with inflammatory bowel disease, a well-documented form of inflammation-driven GI injury. We hope this review will raise awareness and vigilance among clinicians of these entities to increase early diagnosis and rapid referral to specialist care.
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Affiliation(s)
- Pingxin Zhang
- Department of Gastroenterology, The First
Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province,
China
| | - Ren Mao
- Department of Gastroenterology, The First
Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province,
China
| | - Chuhan Zhang
- Department of Gastroenterology, The First
Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province,
China
| | | | - Minhu Chen
- Department of Gastroenterology, The First
Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province,
China
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Kouidhi S, Zidi O, Belkhiria Z, Rais H, Ayadi A, Ben Ayed F, Mosbah A, Cherif A, El Gaaied ABA. Gut microbiota, an emergent target to shape the efficiency of cancer therapy. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2023; 4:240-265. [PMID: 37205307 PMCID: PMC10185446 DOI: 10.37349/etat.2023.00132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 01/04/2023] [Indexed: 05/21/2023] Open
Abstract
It is now well-acknowledged that microbiota has a profound influence on both human health and illness. The gut microbiota has recently come to light as a crucial element that influences cancer through a variety of mechanisms. The connections between the microbiome and cancer therapy are further highlighted by a number of preclinical and clinical evidence, suggesting that these complicated interactions may vary by cancer type, treatment, or even by tumor stage. The paradoxical relationship between gut microbiota and cancer therapies is that in some cancers, the gut microbiota may be necessary to maintain therapeutic efficacy, whereas, in other cancers, gut microbiota depletion significantly increases efficacy. Actually, mounting research has shown that the gut microbiota plays a crucial role in regulating the host immune response and boosting the efficacy of anticancer medications like chemotherapy and immunotherapy. Therefore, gut microbiota modulation, which aims to restore gut microbial balance, is a viable technique for cancer prevention and therapy given the expanding understanding of how the gut microbiome regulates treatment response and contributes to carcinogenesis. This review will provide an outline of the gut microbiota's role in health and disease, along with a summary of the most recent research on how it may influence the effectiveness of various anticancer medicines and affect the growth of cancer. This study will next cover the newly developed microbiota-targeting strategies including prebiotics, probiotics, and fecal microbiota transplantation (FMT) to enhance anticancer therapy effectiveness, given its significance.
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Affiliation(s)
- Soumaya Kouidhi
- Laboratory BVBGR-LR11ES31, Biotechnopole Sidi Thabet, University Manouba, ISBST, Ariana 2020, Tunisia
- Association Tunisienne de Lutte contre le Cancer (ATCC), Tunis, Tunisia
- Correspondence: Soumaya Kouidhi, Laboratory BVBGR-LR11ES31, Biotechnopole Sidi Thabet, University Manouba, ISBST, Ariana 2020, Tunisia; Association Tunisienne de Lutte contre le Cancer (ATCC), Tunis, Tunisia. ;
| | - Oumaima Zidi
- Laboratory BVBGR-LR11ES31, Biotechnopole Sidi Thabet, University Manouba, ISBST, Ariana 2020, Tunisia
- Department of Biologu, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis 1068, Tunisia
| | | | - Henda Rais
- Association Tunisienne de Lutte contre le Cancer (ATCC), Tunis, Tunisia
- Service d’Oncologie Médicale, Hôpital Salah-Azaïz, Tunis 1006, Tunisia
| | - Aida Ayadi
- Department of Pathology, Abderrahman Mami Hospital, University of Tunis El Manar, Ariana 2080, Tunisia
| | - Farhat Ben Ayed
- Association Tunisienne de Lutte contre le Cancer (ATCC), Tunis, Tunisia
| | - Amor Mosbah
- Laboratory BVBGR-LR11ES31, Biotechnopole Sidi Thabet, University Manouba, ISBST, Ariana 2020, Tunisia
| | - Ameur Cherif
- Laboratory BVBGR-LR11ES31, Biotechnopole Sidi Thabet, University Manouba, ISBST, Ariana 2020, Tunisia
| | - Amel Ben Ammar El Gaaied
- Laboratory of Genetics, Immunology and Human Pathology, Department of Biology, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis 1068, Tunisia
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Holmstroem RB, Nielsen OH, Jacobsen S, Riis LB, Theile S, Bjerrum JT, Vilmann P, Johansen JS, Boisen MK, Eefsen RHL, Marie Svane I, Nielsen DL, Chen IM. COLAR: open-label clinical study of IL-6 blockade with tocilizumab for the treatment of immune checkpoint inhibitor-induced colitis and arthritis. J Immunother Cancer 2022; 10:jitc-2022-005111. [PMID: 36096534 PMCID: PMC9472120 DOI: 10.1136/jitc-2022-005111] [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] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Immune-related adverse events due to immune checkpoint inhibitors (ICIs) are not always effectively treated using glucocorticoids and it may negatively affect the antitumor efficacy of ICIs. Interventional studies of alternatives to glucocorticoids are lacking. We examined whether interleukin-6 blockade by tocilizumab reduced ICI-induced colitis and arthritis. Patients and methods Patients with solid cancer experiencing Common Terminology Criteria for Adverse Events (CTCAE v5.0) grade >1 ICI-induced colitis/diarrhea (n=9), arthritis (n=9), or both (n=2) were recruited and treated with tocilizumab (8 mg/kg) every 4 weeks until worsening or unacceptable toxicity. Patients were not allowed to receive systemic glucocorticoids and other immunosuppressive drugs within the 14-day screening period. The primary endpoint was clinical improvement of colitis and arthritis, defined as ≥1 grade CTCAE reduction within 8 weeks. Secondary endpoints were improvements and glucocorticoid-free remission at week 24; safety; radiologic, endoscopic, and histological changes; and changes in plasma concentrations of C reactive protein, cytokines (IL-6, IL-8, and IL-17), and YKL-40. Results Nineteen patients were available for efficacy analysis; one patient was excluded due to pancreatic insufficiency-induced diarrhea. Patients received treatment with pembrolizumab (n=10) or nivolumab (n=4) as monotherapy or ipilimumab and nivolumab (n=5) combined. Seven patients had been initially treated with glucocorticoids, and two of them also received infliximab. Ten patients continued ICI therapy during tocilizumab treatment. The primary endpoint was achieved in 15 of 19 (79%) patients. Additional one patient had ≥1 grade reduction at week 10, and another patient had stabilized symptoms. At week 24, ongoing improvement without glucocorticoids (n=12), including complete remission (n=10), was noted. Five patients had grades 3–4 treatment-related adverse events, which were manageable and reversible. Conclusions Tocilizumab showed promising clinical efficacy and a manageable safety profile in the treatment of ICI-induced colitis and arthritis. Our findings support the feasibility of randomized trials of immune-related adverse events. Trial registration number NCT03601611.
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Affiliation(s)
- Rikke Boedker Holmstroem
- National Center for Cancer Immunotherapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.,Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Ole Haagen Nielsen
- Department of Gastroenterology, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Søren Jacobsen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark.,Copenhagen Lupus and Vasculitis Clinic, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lene Buhl Riis
- Department of Pathology, Copenhagen University Hospital, Herlev, Denmark
| | - Susann Theile
- Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Jacob Tveiten Bjerrum
- Department of Gastroenterology, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Peter Vilmann
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark.,Gastrounit - Division of Surgery, Copenhagen University Hospital, Herlev, Denmark
| | - Julia Sidenius Johansen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark.,Department of Medicine, Copenhagen University Hospital, Herlev, Denmark
| | | | | | - Inge Marie Svane
- National Center for Cancer Immunotherapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.,Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Dorte Lisbet Nielsen
- Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
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14
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Amiot A, Laharie D, Malamut G, Serrero M, Poullenot F. Management of immune checkpoint inhibitor in patients with cancer and pre-existing inflammatory bowel disease: Recommendations from the GETAID. Dig Liver Dis 2022; 54:1162-1167. [PMID: 35842365 DOI: 10.1016/j.dld.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS There is no consensus on the management of immune checkpoint inhibitor (ICI) for treating cancer in patients with pre-existing inflammatory bowel disease (IBD). The Groupe d'Étude Thérapeutique des Affections Inflammatoires du tube Digestif (GETAID) aimed to provide recommendations on this topic. METHODS A dedicated working group performed a comprehensive expert-based review of the literature, generated clinical key question and shaped recommendations that were further voted for approval by the educational and scientific committees of the GETAID. Using consensus methods, treatment modalities were defined by vote. RESULTS Majority of patients with IBD in clinical remission can be treated with ICI after cancer diagnosis. The rate of relapse or immune-related diarrhoea or colitis upon ICI treatment is up to 39.8% and is maximal with ICI combination therapy compared to monotherapies. When starting ICI in a patient with IBD, it is recommended to assess disease activity and pursue ongoing maintenance therapy. In case of relapse or immune-related diarrhoea or colitis upon ICI treatment, treatment depends on grading of diarrhoea or colitis and may include corticosteroid therapy, infliximab and/or vedolizumab. CONCLUSIONS In the present publication, we provided recommendations, which may assist gastroenterologists, haematologists, and oncologists for a better management of patients with pre-existing IBD before and during cancer treatment with ICI.
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Affiliation(s)
- Aurelien Amiot
- Department of Gastroenterology, Hopitaux Universitaires Bicêtre, AP-HP, Universite Paris Est Creteil, Le Kremlin Bicêtre, France; INSERM, Centre for Research in Epidemiology and Population Health, Institut Gustave Roussy, Université Paris Saclay, Villejuif, France.
| | - David Laharie
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service d'Hépato-gastroentérologie et oncologie digestive - Université de Bordeaux, F-33000 Bordeaux, France
| | - Georgia Malamut
- Department of Gastroenterology, AP-HP-Centre, Université de Paris, Hôpital Cochin, Paris, France
| | - Melanie Serrero
- Department of Gastroenterology, University Hospital of Marseille Nord, Aix-Marseille, Marseille University, Marseille, France
| | - Florian Poullenot
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service d'Hépato-gastroentérologie et oncologie digestive - Université de Bordeaux, F-33000 Bordeaux, France
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15
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Alexander JL, Ibraheim H, Richards C, Shum B, Pavlidis P, Hunter N, Teare JP, Wotherspoon A, Furness A, Turajlic S, Pickering L, Larkin J, Speight A, Papa S, Powell N. Oral beclomethasone dipropionate is an effective treatment for immune checkpoint inhibitor induced colitis. J Immunother Cancer 2022; 10:e005490. [PMID: 36113896 PMCID: PMC9486376 DOI: 10.1136/jitc-2022-005490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Systemic corticosteroids are the mainstay of treatment for immune checkpoint inhibitor induced (CPI) colitis but are associated with complications including life-threatening infection. The topically acting oral corticosteroid beclomethasone dipropionate (BD) is an effective treatment for mild to moderate flares of ulcerative colitis, and has fewer side effects than systemic corticosteroids. We hypothesized that BD would be an effective treatment for CPI-induced colitis. METHODS We performed a retrospective analysis of all patients who started BD for CPI-induced colitis at three UK cancer centers between November 2017 and October 2020. All patients underwent endoscopic assessment and biopsy. The initial regimen of BD was 5 mg once daily for 28 days. Data were collected from electronic patient records. Clinical outcomes were assessed at 28 days after initiation of treatment. RESULTS Twenty-two patients (14 male) with a median age of 64 (range 45-84) with CPI-induced colitis were treated with BD. At baseline, the median number of loose stools in a 24-hour period was six (common terminology criteria for adverse events, CTCAE grade diarrhea=2). Thirteen patients (59%) were dependent on systemic corticosteroids prior to starting BD. Baseline sigmoidoscopy showed moderate inflammation (Mayo Endoscopic Score (MES) = 2) in two patients (9%), mild inflammation (MES=1) in nine patients (41%) and normal findings (MES=0) in eleven patients (50%). Twenty patients (91%) had histopathological features of inflammation. All 22 patients (100%) had a clinical response to BD and 21 (95%) achieved clinical remission with a return to baseline stool frequency (CTCAE diarrhea=0). Ten patients (45%) had symptomatic relapse on cessation of BD, half within 7 days of stopping. All patients recaptured response on restarting BD. No adverse events were reported in patients treated with BD. CONCLUSIONS Topical BD represents an appealing alternative option to systemic immunosuppressive treatments to treat colonic inflammation. In this study, BD was effective and safe at inducing remission in CPI-induced colitis, which was refractory to systemic corticosteroids. Further randomized studies are needed to confirm these findings and determine the optimum dosing regimen.
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Affiliation(s)
- James L Alexander
- Department of Gastroenterology, Royal Marsden NHS Foundation Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Hajir Ibraheim
- Department of Gastroenterology, Royal Marsden NHS Foundation Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Camellia Richards
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Ben Shum
- Renal & Skin Units, Royal Marsden NHS Foundation Trust, London, UK
| | - Polychronis Pavlidis
- Experimental Immunobiology, King's College London, London, UK
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
| | - Nikki Hunter
- Renal & Skin Units, Royal Marsden NHS Foundation Trust, London, UK
| | - Julian P Teare
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Andrew Wotherspoon
- Department of Histopathology, Royal Marsden NHS Foundation Trust, London, UK
| | - Andrew Furness
- Renal & Skin Units, Royal Marsden NHS Foundation Trust, London, UK
| | - Samra Turajlic
- Renal & Skin Units, Royal Marsden NHS Foundation Trust, London, UK
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - Lisa Pickering
- Renal & Skin Units, Royal Marsden NHS Foundation Trust, London, UK
| | - James Larkin
- Renal & Skin Units, Royal Marsden NHS Foundation Trust, London, UK
| | - Ally Speight
- Department of Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Sophie Papa
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Nick Powell
- Department of Gastroenterology, Royal Marsden NHS Foundation Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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16
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Abstract
OPINION STATEMENT Immune checkpoint inhibitors (ICIs) have become an essential part of treatment for many cancer types. These monoclonal antibodies remove a critical negative regulatory signal that allows the immune system to recognize and destroy malignant cells that were previously undetectable. Unfortunately, their use has ushered in a whole new form of drug toxicity whereby the immune system attacks normal tissues in the body, referred to hereafter as immune-related adverse events (irAEs). irAEs are common and can result in treatment discontinuation, hospitalization, and death. When alternative modes of treatment are limited, or considered less efficacious, there may be a desire to resume treatment with ICIs after an irAE. Rechallenge with ICIs carries with it a heightened risk of subsequent toxicity, but with careful consideration and appropriate patient selection, this can be considered a reasonable approach.
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17
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Leblanc J, Hoibian S, Boucraut A, Ratone JP, Stoffaes L, Dano D, Louvel-Perrot D, Chanez B, Chretien AS, Madroszyk A, Rochigneux P. Celiac Disease After Administration of Immune Checkpoint Inhibitors: A Case Report. Front Immunol 2022; 12:799666. [PMID: 34975913 PMCID: PMC8718638 DOI: 10.3389/fimmu.2021.799666] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 11/30/2021] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) reinvigorate the immune system to recognize and destroy tumor cells. Because of this biological mechanism, patients might develop autoimmune toxicities, notably in the digestive tract (most frequently, hepatitis or colitis). A 70-year-old man with relapsed mesothelioma was treated with nivolumab in 3rd line. He was hospitalized for watery and foul-smelling diarrhea. He underwent gastrointestinal endoscopy, showing duodenitis and villous atrophy and measurement of serum IgA antibodies to tissue transglutaminase (tTG-IgA+), leading to the diagnosis of ICI-induced celiac disease. He was treated with steroids, proton pump inhibitors, and a gluten-free diet. If ICI-induced celiac disease is rare in the literature, increasing reports suggest that celiac disease might represent an underestimated ICI toxicity. This case highlights the necessity of complementary investigation (including tTG-IgA and endoscopic biopsies) in patients with atypical digestive symptoms during immunotherapy.
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Affiliation(s)
- Julie Leblanc
- Medical Oncology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Solene Hoibian
- Gastroenterology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Agathe Boucraut
- Pathology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Jean-Philippe Ratone
- Gastroenterology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Louis Stoffaes
- Medical Oncology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Domitille Dano
- Medical Oncology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Delphine Louvel-Perrot
- Medical Oncology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Brice Chanez
- Medical Oncology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Anne-Sophie Chretien
- Team Immunity and Cancer, Centre de Recherche en Cancérologie de Marseille (CRCM), Inserm, U1068, CNRS, UMR7258, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Anne Madroszyk
- Medical Oncology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
| | - Philippe Rochigneux
- Medical Oncology Department, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France.,Team Immunity and Cancer, Centre de Recherche en Cancérologie de Marseille (CRCM), Inserm, U1068, CNRS, UMR7258, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France
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18
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Bai X, Wang X, Ma G, Song J, Liu X, Wu X, Zhao Y, Liu X, Liu Z, Zhang W, Zhao X, Zheng Z, Jing J, Shi H. Improvement of PD-1 Blockade Efficacy and Elimination of Immune-Related Gastrointestinal Adverse Effect by mTOR Inhibitor. Front Immunol 2022; 12:793831. [PMID: 34987517 PMCID: PMC8721049 DOI: 10.3389/fimmu.2021.793831] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/02/2021] [Indexed: 02/05/2023] Open
Abstract
During the past decades, immunotherapy, especially the antibody-mediated immune checkpoint blockade (ICB) has shown durable tumor inhibition and changed the paradigm of cancer treatment. However, a growing body of evidence suggests that ICB treatment induces severe immune-related adverse events (irAEs), and the side effect even leads to the discontinuation of lifesaving treatment. Here, we found that ICB treatment induces colitis in melanoma patients and promotes the infiltration of CD8+ effector T cells into colitic lesions. Further transcriptomic dissection indicated the PI3K-AKT-mTOR pathway was highly activated in CD8+ effector T cells of colitic lesions. Moreover, we developed a mouse melanoma model to recapitulate the gastrointestinal toxicity of anti-PD-1 treatment in clinical settings. Anti-PD-1 treatment significantly contributed to the infiltration of CD8+ T cells, and correspondingly induced severe enteritis. Immunohistochemistry experiments showed that the PI3K-AKT-mTOR pathway of T cells was activated by anti-PD-1 treatment. Blockade of the pathway with mTOR inhibitor sirolimus not only inhibits tumor growth but also suppresses the T cell infiltration in colitic lesions. More importantly, combination with sirolimus and anti-PD-1 synergistically inhibits tumor growth via inducing the immunogenic cell death of tumor cells in vivo. In summary, our research demonstrated the principle of mTOR inhibitor and anti-PD-1 combinatorial therapeutic regimen, which provided a novel therapeutic strategy for irAEs in clinics.
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Affiliation(s)
- Xin Bai
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Xueyan Wang
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Guozhen Ma
- Microbial Innovation and Development Department, Chemical Manufacturing and Control (CMC) Center, Hangzhou Zhong Mei Hua Dong Pharmaceutical Co., Ltd., Hangzhou, China
| | - Jinen Song
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Xiaowei Liu
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Xi Wu
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Yujie Zhao
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Xu Liu
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Zhihui Liu
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Wei Zhang
- Microbial Innovation and Development Department, Chemical Manufacturing and Control (CMC) Center, Hangzhou Zhong Mei Hua Dong Pharmaceutical Co., Ltd., Hangzhou, China
| | - Xin Zhao
- Microbial Innovation and Development Department, Chemical Manufacturing and Control (CMC) Center, Hangzhou Zhong Mei Hua Dong Pharmaceutical Co., Ltd., Hangzhou, China
| | - Zirui Zheng
- Microbial Innovation and Development Department, Chemical Manufacturing and Control (CMC) Center, Hangzhou Zhong Mei Hua Dong Pharmaceutical Co., Ltd., Hangzhou, China
| | - Jing Jing
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
| | - Hubing Shi
- Laboratory of Integrative Medicine, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China
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19
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Jones A, Rodgers K, Jeffrey D, Ali WI, Andreyev HJN. Nivolumab-induced exocrine pancreatic insufficiency. Frontline Gastroenterol 2021; 14:167-170. [PMID: 36818802 PMCID: PMC9933604 DOI: 10.1136/flgastro-2021-102013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/07/2021] [Indexed: 02/24/2023] Open
Abstract
Immune checkpoint inhibition is the standard-of-care for many advanced cancers. Side effects of therapy may prevent optimal treatment of the cancer. Management of side effects is dominated by recommendations derived from oncological, not gastroenterological practice. We report a patient who developed pancreatic insufficiency during checkpoint inhibitor therapy with a programmed cell death receptor 1 inhibitor, nivolumab, which if not diagnosed would have prevented ongoing treatment. This is a problem which affects approximately 1 in 100 patients treated with this agent but is rarely recognised. Gastroenterologists need to be aware of the spectrum of gastrointestinal disorders which occur after immunotherapy to treat cancer.
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Affiliation(s)
- Anna Jones
- Research & Innovation Team, Lincolnshire Community Health Services NHS Trust, Lincoln, UK
| | - Kay Rodgers
- Research & Innovation Team, Lincolnshire Community Health Services NHS Trust, Lincoln, UK
| | - Debbie Jeffrey
- Research & Innovation Team, Lincolnshire Community Health Services NHS Trust, Lincoln, UK
| | - Waqas I Ali
- Oncology, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
| | - HJN Andreyev
- Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
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20
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da Silva JA, Falcão D, Cardoso C, Pires AL, Araújo A, Castro-Poças F. Hepatic immune-mediatedadverseeffects of immune checkpoint inhibitors: analysis of real-life experience. Ann Hepatol 2021; 26:100561. [PMID: 34653687 DOI: 10.1016/j.aohep.2021.100561] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Immune Checkpoint Inhibitors (ICI) have shifted the paradigm of cancer therapy treatment. Despite their efficacy, ICIs may induce immune-related adverse events (irAE), which can affect various organs, namely the liver. This study intends to perform a comprehensive clinical description of the hepatic irAEs associated with ICI in a Portuguese population of a tertiary hospital centre. MATERIALS AND METHODS A retrospective analysis of patients who developed immune-mediated liver injury (IMLI), among a cohort of patients treated with ICIs between March 15th of 2015 and December 15th of 2019 in a tertiary hospital. We used both Common Terminology Criteria for Adverse Events (CTCAE) and Drug-Induced Liver Injury Network (DILIN) criteria to define liver injury. RESULTS Among 151 patients, eight (5.3%) patients developed liver injury grade ≥3, of which five had hepatic metastasis. As such, only 3 cases were classified as IMLI. All IMLI presented with cholestasis pattern; the median duration from ICI initiation to IMLI was 84 days and/or 4 ICI cycles; one patient registered IMLI one month after nivolumab suspension; all were treated with steroids and one was successfully submitted to ICI re-challenge; a favourable outcome was seen in all patients; the median time to hepatic biochemistries normalization was 150 days. Among 10 patients with previous hepatic conditions, only one developed liver injury grade 2. CONCLUSIONS Clinically significant ICI-related hepatotoxicity was uncommon; Immune-mediated liver injury may present a cholestatic pattern predominance. There was a low rate of liver injury of any kind in patients with previous hepatic disease while on ICI.
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Affiliation(s)
| | - Daniela Falcão
- Gastroenterology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Cláudia Cardoso
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
| | - Ana Luísa Pires
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
| | - António Araújo
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal; Oncology Service, Pathology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Fernando Castro-Poças
- Gastroenterology, Centro Hospitalar Universitário do Porto, Porto, Portugal; Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
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21
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Macovei Oprescu A, Tulin R, Slavu I, Venter DP, Oprescu C. Immune Checkpoint Inhibitor-Induced Gastrointestinal Toxicity: The Opinion of a Gastroenterologist. Cureus 2021; 13:e19945. [PMID: 34976532 PMCID: PMC8711857 DOI: 10.7759/cureus.19945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2021] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are currently an important component of the standard first-line treatment for many neoplasms. Some guidelines recommend ICIs as adjuvant treatment. With their increased use, the incidence of associated immune-mediated adverse reactions will also increase. A significant proportion of these reactions is represented by immune-mediated diarrhea or colitis, hepatitis, and immune-mediated pancreatic damage. The present review aims to highlight the new trends related to the diagnosis and treatment of these adverse effects depending on their degree, from the perspective of the gastroenterologist. To accomplish this, a literature search was performed, and 30 publications were considered relevant (according to the Population, Intervention, Comparison, Outcomes, and Study [PICOS] criteria). The information about each of the three toxicities in this paper was structured in two categories such as differential diagnosis and treatment. This review aims not only to increase awareness of these side effects in the gastroenterology community but also to promote the development of new treatment guidelines with contributions from gastroenterologists.
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Affiliation(s)
- Anca Macovei Oprescu
- Gastroenterology, Agrippa Ionescu Emergency Clinical Hospital, Bucharest, ROU
- Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Raluca Tulin
- Anatomy and Embryology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Endocrinology, Agrippa Ionescu Emergency Clinical Hospital, Bucharest, ROU
| | - Iulian Slavu
- General Surgery, Agrippa Ionescu Emergency Clinical Hospital, Bucharest, ROU
| | - Dana Paula Venter
- Pediatric Surgery, Grigore Alexandrescu Emergency Pediatric Hospital, Bucharest, ROU
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22
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Soma K, Nishida T, Osugi N, Morimura O, Adachi S, Fujii Y, Sugimoto A, Mukai K, Nakamatsu D, Matsumoto K, Yamamoto M. Nivolumab dose escalation triggered immune checkpoint inhibitor-induced colitis after 147 weeks of prolonged stable use in a patient with lung cancer: a case report. Clin J Gastroenterol 2021; 15:128-133. [PMID: 34716545 DOI: 10.1007/s12328-021-01542-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/20/2021] [Indexed: 12/17/2022]
Abstract
A 56-year-old man with advanced lung adenocarcinoma presented to the emergency department with a 6-day history of diarrhea. He was treated for lung cancer with nivolumab 3 mg/kg (144 mg/body) every 2 weeks (Q2W), followed by an increase to 240 mg Q2W for 147 weeks, for a total of 69 administrations. His dose was then increased to 480 mg/body every four weeks (Q4W) 12 days before his presentation. Clostridioides difficile toxin, cytomegalovirus antigenemia, and stool bacterial cultures were negative. Colonoscopy revealed diffusely edematous granular mucosa with mucosal redness, exudates, loss of vascular pattern, and aphtha throughout the colon but no ulcers. We diagnosed the patient with immune checkpoint inhibitor-induced colitis. We started prednisolone at a dose of 60 mg/day. His symptoms gradually improved, and he recovered without diarrhea on day ten after hospitalization. After prednisolone tapering, his symptoms did not worsen. Colonoscopy showed significant improvement on day 29, and the diffuse redness disappeared. The patient did not experience subsequent recurrence of diarrhea. He had no progression of lung cancer despite the termination of nivolumab for seven months. Here, we report a case of lung cancer in which nivolumab dose escalation after prolonged stable use triggered immune checkpoint inhibitor-induced colitis.
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Affiliation(s)
- Kazumasa Soma
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan.
| | - Naoto Osugi
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Osamu Morimura
- Department of Internal Medicine, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Shiro Adachi
- Department of Pathology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yoshifumi Fujii
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Aya Sugimoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Kaori Mukai
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Kengo Matsumoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
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Rizzo A, Mollica V, Santoni M, Massari F. Risk of selected gastrointestinal toxicities in metastatic renal cell carcinoma patients treated with immuno-TKI combinations: a meta-analysis. Expert Rev Gastroenterol Hepatol 2021; 15:1225-1232. [PMID: 34167420 DOI: 10.1080/17474124.2021.1948328] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Recent years have registered the advent of novel treatment options for metastatic renal cell carcinoma (mRCC), including combination therapies with immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs). Immuno-TKI combinations have been suggested to improve clinical outcomes but may also result in increased toxicity, including gastrointestinal (GI) adverse events. METHODS Herein, we performed a meta-analysis aimed at comparing the risk of certain GI toxicities in mRCC patients treated with immuno-TKI combinations versus sunitinib monotherapy. Overall, four phase III trials (KEYNOTE-426, JAVELIN Renal 101, CheckMate 9ER, CLEAR) involving 3059 mRCC patients were available. RESULTS The meta-analysis suggested an increased risk of all-grade diarrhea, grade 3-4 diarrhea and grade 3-4 decreased appetite in patients treated with immuno-TKI combinations. Conversely, an apparently higher risk of all-grade nausea was observed in the sunitinib group. CONCLUSION The meta-analysis suggested that immuno-TKI combinations are associated with higher risk of GI toxicities compared with sunitinib. Beyond the efficacy of immuno-TKI combinations in mRCC patients, careful consideration should be given to treatment-related adverse events, including GI toxicities. Early recognition and treatment are critical to maximize recovery.
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Affiliation(s)
- Alessandro Rizzo
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italia
| | - Veronica Mollica
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italia
| | | | - Francesco Massari
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italia
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24
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Wang Y, Jiao X, Li S, Chen H, Wei X, Liu C, Gong J, Zhang X, Wang X, Peng Z, Qi C, Wang Z, Wang Y, Zhuo N, Zou J, Zhang H, Li J, Shen L, Lu Z. Alterations in DNA damage response and repair genes as potential biomarkers for immune checkpoint blockade in gastrointestinal cancer. Cancer Biol Med 2021; 19:j.issn.2095-3941.2020.0708. [PMID: 34570439 PMCID: PMC9425187 DOI: 10.20892/j.issn.2095-3941.2020.0708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/06/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) have achieved remarkable results in cancer treatments. However, there is no effective predictive biomarker for gastrointestinal (GI) cancer. METHODS We conducted integrative analyses of the genomic and survival data of ICI-treated GI cancer patients from the Memorial Sloan Kettering Cancer Center cohort (MSK-GI, n = 227), the Janjigian cohort (n = 40), and the Peking University Cancer Hospital & Institute cohort (PUCH, n = 80) to determine the possible associations between DNA damage response and repair (DDR) gene mutations and clinical outcomes. Data from The Cancer Genome Atlas database were analyzed to determine the possible correlations between DDR gene mutations and the tumor microenvironment. RESULTS In the MSK cohort, the presence of ≥ 2 DDR gene mutations was correlated with prolonged overall survival (OS). The Janjigian and PUCH cohorts further confirmed that subgroups with ≥ 2 DDR gene mutations displayed a prolonged OS and a higher durable clinical benefit. Furthermore, the DDR gene mutation load could be considered as an independent prognostic factor, and exhibited a potential predictive value for survival in GI cancer patients treated with ICIs. Mechanistically, we showed that the presence of ≥ 2 DDR gene mutations was correlated with higher levels of tumor mutation burden, neoantigen, and T cell infiltration. CONCLUSIONS The DDR gene mutation status was correlated with favorable clinical outcomes in GI cancer patients receiving ICIs, which could serve as a potential biomarker to guide patient selection for immunotherapy.
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Affiliation(s)
- Yujiao Wang
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xi Jiao
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Shuang Li
- Department of Gastric & Colorectal Surgery, The First Hospital of Jilin University, Changchun 130021, China
| | - Huan Chen
- Genecast Precision Medicine Technology Institute, Beijing 100192, China
| | - Xin Wei
- Life Sciences Institute, Zhejiang University, Hangzhou 310058, China
| | - Chang Liu
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jifang Gong
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiaotian Zhang
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xicheng Wang
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Zhi Peng
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Changsong Qi
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Zhenghang Wang
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yanni Wang
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Na Zhuo
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jianling Zou
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Henghui Zhang
- Institute of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Jian Li
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Lin Shen
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Zhihao Lu
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
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Sanceau J, Gougelet A. Epigenetic mechanisms of liver tumor resistance to immunotherapy. World J Hepatol 2021; 13:979-1002. [PMID: 34630870 PMCID: PMC8473495 DOI: 10.4254/wjh.v13.i9.979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/04/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver tumor, which stands fourth in rank of cancer-related deaths worldwide. The incidence of HCC is constantly increasing in correlation with the epidemic in diabetes and obesity, arguing for an urgent need for new treatments for this lethal cancer refractory to conventional treatments. HCC is the paradigm of inflammation-associated cancer, since more than 80% of HCC emerge consecutively to cirrhosis associated with a vast remodeling of liver microenvironment. In the recent decade, immunomodulatory drugs have been developed and have given impressive results in melanoma and later in several other cancers. In the present review, we will discuss the recent advancements concerning the use of immunotherapies in HCC, in particular those targeting immune checkpoints, used alone or in combination with other anti-cancers agents. We will address why these drugs demonstrate unsatisfactory results in a high proportion of liver cancers and the mechanisms of resistance developed by HCC to evade immune response with a focus on the epigenetic-related mechanisms.
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Affiliation(s)
- Julie Sanceau
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Paris 75006, France
| | - Angélique Gougelet
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Paris 75006, France
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26
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Gómez-Escudero O, Remes-Troche JM. Approach to the adult patient with chronic diarrhea: A literature review. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 86:387-402. [PMID: 34389290 DOI: 10.1016/j.rgmxen.2021.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia y Motilidad Gastrointestinal, Hospital Ángeles Puebla, Puebla, Mexico.
| | - J M Remes-Troche
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
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27
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Lo YC, Price C, Blenman K, Patil P, Zhang X, Robert ME. Checkpoint Inhibitor Colitis Shows Drug-Specific Differences in Immune Cell Reaction That Overlap With Inflammatory Bowel Disease and Predict Response to Colitis Therapy. Am J Clin Pathol 2021; 156:214-228. [PMID: 33555016 DOI: 10.1093/ajcp/aqaa217] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Checkpoint inhibitor (CPI)-associated colitis can limit therapy and has resemblance to inflammatory bowel disease (IBD). Studies exploring mechanistic similarities between these colitides are limited, yet therapeutic targets for either disorder could emerge from shared pathophysiology. METHODS The morphology and inflammatory content of colonic biopsy specimens from anti-CTLA-4 and anti-PD-1/PD-L1 antibody-treated patients with CPI colitis were compared with initial biopsy specimens from patients with IBD. Predictors of the need for infliximab were sought in CPI patients. RESULTS Biopsy specimens from CPI patients showed significantly lower chronicity scores and similar activity scores compared with patients with IBD. Anti-CTLA-4 and IBD groups showed equivalent CD8, CD4, PD-1, and PD-L1 expression, while FoxP3 scores were lower and CD68 scores were higher in anti-CTLA-4 compared with IBD biopsy specimens. Anti-PD-1/PD-L1 group had lower scores for CD8, CD4, and PD-1 and equivalent scores for FoxP3, PD-L1, and CD68 compared with IBD. Anti-CTLA-4 biopsy specimens had higher scores for CD8, PD-1, PD-L1, and CD68 than anti-PD-1/PD-L1 biopsy specimens. CD8/FoxP3 ratios and CD68 scores were higher among CPI patients requiring infliximab therapy for colitis compared with those responding to steroids. CONCLUSIONS The proinflammatory immune phenotype of anti-CTLA-4-associated colitis has significant overlap with IBD. CD8/FoxP3 ratios may predict therapeutic response in CPI-associated colitis.
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Affiliation(s)
- Ying-Chun Lo
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Christina Price
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kim Blenman
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - Pallavi Patil
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Xuchen Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Marie E Robert
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
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28
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Mohiuddin JJ, Chu B, Facciabene A, Poirier K, Wang X, Doucette A, Zheng C, Xu W, Anstadt EJ, Amaravadi RK, Karakousis GC, Mitchell TC, Huang AC, Shabason JE, Lin A, Swisher-McClure S, Maity A, Schuchter LM, Lukens JN. Association of Antibiotic Exposure With Survival and Toxicity in Patients With Melanoma Receiving Immunotherapy. J Natl Cancer Inst 2021; 113:162-170. [PMID: 32294209 DOI: 10.1093/jnci/djaa057] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/20/2020] [Accepted: 04/08/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Gut microbial diversity is associated with improved response to immune checkpoint inhibitors (ICI). Based on the known detrimental impact that antibiotics have on microbiome diversity, we hypothesized that antibiotic receipt prior to ICI would be associated with decreased survival. METHODS Patients with stage III and IV melanoma treated with ICI between 2008 and 2019 were selected from an institutional database. A window of antibiotic receipt within 3 months prior to the first infusion of ICI was prespecified. The primary outcome was overall survival (OS), and secondary outcomes were melanoma-specific mortality and immune-mediated colitis requiring intravenous steroids. All statistical tests were two-sided. RESULTS There were 568 patients in our database of which 114 received antibiotics prior to ICI. Of the patients, 35.9% had stage III disease. On multivariable Cox proportional hazards analysis of patients with stage IV disease, the antibiotic-exposed group had statistically significantly worse OS (hazard ratio [HR] = 1.81, 95% confidence interval [CI] = 1.27 to 2.57; P <.001). The same effect was observed among antibiotic-exposed patients with stage III disease (HR = 2.78, 95% CI = 1.31 to 5.87; P =.007). When limited to only patients who received adjuvant ICI (n = 89), antibiotic-exposed patients also had statistically significantly worse OS (HR = 4.84, 95% CI = 1.09 to 21.50; P =.04). The antibiotic group had a greater incidence of colitis (HR = 2.14, 95% CI = 1.02 to 4.52; P =.046). CONCLUSION Patients with stage III and IV melanoma exposed to antibiotics prior to ICI had statistically significantly worse OS than unexposed patients. Antibiotic exposure was associated with greater incidence of moderate to severe immune-mediated colitis. Given the large number of antibiotics prescribed annually, physicians should be judicious with their use in cancer populations likely to receive ICI.
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Affiliation(s)
- Jahan J Mohiuddin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Chu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrea Facciabene
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kendra Poirier
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Xingmei Wang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Abigail Doucette
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Cathy Zheng
- Tara Miller Melanoma Center, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Wei Xu
- Tara Miller Melanoma Center, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily J Anstadt
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ravi K Amaravadi
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Division of Endocrine and Oncologic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Tara C Mitchell
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander C Huang
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob E Shabason
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Amit Maity
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lynn M Schuchter
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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29
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Patil PA, Zhang X. Pathologic Manifestations of Gastrointestinal and Hepatobiliary Injury in Immune Checkpoint Inhibitor Therapy. Arch Pathol Lab Med 2021; 145:571-582. [PMID: 32338534 DOI: 10.5858/arpa.2020-0070-ra] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 02/05/2023]
Abstract
CONTEXT.— Immune checkpoint inhibitors (CPIs), including cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors and the programmed death receptor-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors, are being increasingly used for treating many advanced malignancies. However, CPI therapy is also associated with gastrointestinal and hepatobiliary adverse effects. OBJECTIVES.— To review the adverse effects of CPI therapy on the gastrointestinal tract and hepatobiliary system. To describe histopathologic patterns and discuss differential diagnostic considerations in the diagnosis of CPI injuries. DATA SOURCES.— Published peer-reviewed literature in the English language and personal experience in the diagnosis of CPI injuries. CONCLUSIONS.— The pathologic manifestations of CPI therapy-induced gastrointestinal and hepatobiliary injury are broad. The patterns of esophageal CPI injury include lymphocytic inflammation and ulcerative esophagitis, while those of gastric injury include chronic active gastritis, lymphocytic gastritis, focal enhancing gastritis, and periglandular inflammation. The duodenal injury may present as duodenitis with villous blunting and granulomas. We also noticed active colitis, microscopic colitis, chronic active colitis, increased apoptosis, ischemic colitis, and nonspecific inflammatory reactive changes in colonic injuries. The reported histologic features of hepatobiliary injuries are panlobular hepatitis, centrilobular necrosis, portal inflammation with bile duct injury, steatosis, nodular regenerative hyperplasia, and secondary sclerosing cholangitis. In summary, we discuss the pathologic features and differential diagnosis of CPI therapy-induced gastrointestinal and hepatobiliary injury. Recognition of CPI injury is important to determine the proper management that often includes cessation of CPI therapy, and administration of steroids or other immunosuppressive agents, based on severity of injury.
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Affiliation(s)
- Pallavi A Patil
- From the Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Xuchen Zhang
- From the Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
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30
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Gómez-Escudero O, Remes-Troche JM. Approach to the adult patient with chronic diarrhea: a literature review. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2021; 86:S0375-0906(21)00038-0. [PMID: 34074557 DOI: 10.1016/j.rgmx.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/22/2022]
Abstract
Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia y Motilidad Gastrointestinal, Hospital Ángeles Puebla, Puebla, México.
| | - J M Remes-Troche
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, México
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31
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Shen S, Dai H, Fei Z, Chai Y, Hao Y, Fan Q, Dong Z, Zhu Y, Xu J, Ma Q, Han X, Xu L, Peng F, Liu Z, Wang C. Immunosuppressive Nanoparticles for Management of Immune-Related Adverse Events in Liver. ACS NANO 2021; 15:9111-9125. [PMID: 33988024 DOI: 10.1021/acsnano.1c02391] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Immune checkpoint blockade (ICB) therapy has been considered as an effective way to boost immune cells to recognize and attack tumors. However, side effects known as immune-related adverse events (irAEs) should be carefully managed. Here, we engineer immunosuppressive nanoparticles by coating PD-L1 overexpressed mesenchymal stem cells (MSCs) plasma membrane on poly lactic-co-glycolic acid nanoparticles (MSC-PD-L1+ NPs) for managing and reducing irAEs induced by immune checkpoint inhibitors. The nanoparticles can enrich at liver site after intravenous administration. In the high dose of anti-PD-L1 mAb-induced irAEs clinically relevant mouse model, a low dose of MSC-PD-L1+ NPs (2 mg/kg) sufficiently rescues hepatitis by inactivating T cells and macrophages in the liver tissue. More intriguingly, due to the dose threshold for nanoparticles to the tumor site, we unexpectedly find that the injected NPs do not affect the efficiency of ICB therapy to inhibit solid tumor growth. Such a strategy shows potential for managing the various cancer immunotherapy associated irAEs in clinical applications.
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Affiliation(s)
- Shufang Shen
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Huaxing Dai
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Ziying Fei
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Yu Chai
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Yu Hao
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Qin Fan
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Ziliang Dong
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Yujie Zhu
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Jialu Xu
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Qingle Ma
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Xiao Han
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Ligeng Xu
- The First Affiliated Hospital, Department of Chemistry, Jinan University, Guangzhou 510632, China
| | - Fei Peng
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts 02114, United States
| | - Zhuang Liu
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
| | - Chao Wang
- Institute of Functional Nano & Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu 215123, China
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Go DM, Lee SH, Lee SH, Woo SH, Kim K, Kim K, Park KS, Park JH, Ha SJ, Kim WH, Choi JH, Kim DY. Programmed Death Ligand 1-Expressing Classical Dendritic Cells MitigateHelicobacter-Induced Gastritis. Cell Mol Gastroenterol Hepatol 2021; 12:715-739. [PMID: 33894424 PMCID: PMC8267570 DOI: 10.1016/j.jcmgh.2021.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Helicobacter pylori has been reported to modulate local immune responses to colonize persistently in gastric mucosa. Although the induced expression of programmed cell death ligand 1 (PD-L1) has been suggested as an immune modulatory mechanism for persistent infection of H pylori, the main immune cells expressing PD-L1 and their functions in Helicobacter-induced gastritis still remain to be elucidated. METHODS The blockades of PD-L1 with antibody or PD-L1-deficient bone marrow transplantation were performed in Helicobacter-infected mice. The main immune cells expressing PD-L1 in Helicobacter-infected stomach were determined by flow cytometry and immunofluorescence staining. Helicobacter felis or H pylori-infected dendritic cell (DC)-deficient mouse models including Flt3-/-, Zbtb46-diphtheria toxin receptor, and BDCA2-diphtheria toxin receptor mice were analyzed for pathologic changes and colonization levels. Finally, the location of PD-L1-expressing DCs and the correlation with H pylori infection were analyzed in human gastric tissues using multiplexed immunohistochemistry. RESULTS Genetic or antibody-mediated blockade of PD-L1 aggravated Helicobacter-induced gastritis with mucosal metaplasia. Gastric classical DCs expressed considerably higher levels of PD-L1 than other immune cells and co-localized with T cells in gastritis lesions from Helicobacter-infected mice and human beings. H felis- or H pylori-infected Flt3-/- or classical DC-depleted mice showed aggravated gastritis with severe T-cell and neutrophil accumulation with low bacterial loads compared with that in control mice. Finally, PD-L1-expressing DCs were co-localized with T cells and showed a positive correlation with H pylori infection in human subjects. CONCLUSIONS The PD-1/PD-L1 pathway may be responsible for the immune modulatory function of gastric DCs that protects the gastric mucosa from Helicobacter-induced inflammation, but allows persistent Helicobacter colonization.
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Affiliation(s)
- Du-Min Go
- Department of Veterinary Pathology, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Seung Hyun Lee
- Department of Life Sciences, College of Natural Sciences, Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea
| | - Su-Hyung Lee
- Division of Cancer Biology, Research Institute of National Cancer Center, Gyeonggi-do, Republic of Korea
| | - Sang-Ho Woo
- Department of Veterinary Pathology, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Kibyeong Kim
- Department of Life Sciences, College of Natural Sciences, Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea
| | - Kyeongdae Kim
- Department of Life Sciences, College of Natural Sciences, Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea
| | - Kyu Seong Park
- Department of Life Sciences, College of Natural Sciences, Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea
| | - Jong-Hwan Park
- Laboratory Animal Medicine, College of Veterinary Medicine, Chonnam National University, Gwangju, Republic of Korea
| | - Sang-Jun Ha
- Department of Biochemistry, College of Life Science and Biotechnology, Yonsei University, Seoul, Republic of Korea
| | - Woo Ho Kim
- Department of Pathology, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jae-Hoon Choi
- Department of Life Sciences, College of Natural Sciences, Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea.
| | - Dae-Yong Kim
- Department of Veterinary Pathology, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea.
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Kichloo A, Albosta M, Dahiya D, Guidi JC, Aljadah M, Singh J, Shaka H, Wani F, Kumar A, Lekkala M. Systemic adverse effects and toxicities associated with immunotherapy: A review. World J Clin Oncol 2021; 12:150-163. [PMID: 33767971 PMCID: PMC7968107 DOI: 10.5306/wjco.v12.i3.150] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/21/2021] [Accepted: 02/20/2021] [Indexed: 02/06/2023] Open
Abstract
Immunotherapy is rapidly evolving secondary to the advent of newer immunotherapeutic agents and increasing approval of the current agents by the United States Food and Drug Administration to treat a wide spectrum of cancers. Immunotherapeutic agents have gained immense popularity due to their tumor-specific action. Immunotherapy is slowly transforming into a separate therapeutic entity, and the fifth pillar of management for cancers alongside surgery, radiotherapy, chemotherapy, and targeted therapy. However, like any therapeutic entity it has its own adverse effects. With the increasing use of immuno-therapeutic agents, it is vital for physicians to acquaint themselves with these adverse effects. The aim of this review is to investigate the common systemic adverse effects and toxicities associated with the use of different classes of immunotherapeutic agents. We provide an overview of potential adverse effects and toxicities associated with different classes of immunotherapeutic agents organized by organ systems, as well as an extensive discussion of the current recommendations for treatment and clinical trial data. As we continue to see increasing usage of these agents in clinical practice, it is vital for physicians to familiarize themselves with these effects.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Michael Albosta
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Dushyant Dahiya
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Jean Claude Guidi
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Michael Aljadah
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 53201, United States
| | - Jagmeet Singh
- Department of Nephrology, Guthrie Robert Packer Hospital, Sayre, PA 18840, United States
| | - Hafeez Shaka
- Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, IL 60612, United States
| | - Farah Wani
- Department of Family Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Akshay Kumar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Manidhar Lekkala
- Department of Hematology and Oncology, University of Rochester Medical Center, Rochester, NY 14642, United States
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34
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Irshaid L, Robert ME, Zhang X. Immune Checkpoint Inhibitor-Induced Upper Gastrointestinal Tract Inflammation Shows Morphologic Similarities to, but Is Immunologically Distinct From, Helicobacter pylori Gastritis and Celiac Disease. Arch Pathol Lab Med 2021; 145:191-200. [PMID: 33501492 DOI: 10.5858/arpa.2019-0700-oa] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 02/05/2023]
Abstract
CONTEXT.— Immune checkpoint inhibitor (CPI) therapies are associated with multi-organ immune-related adverse events. Although colonic mucosal changes have been described, inflammatory changes incited by CPIs in the upper gastrointestinal tract have not been well characterized. OBJECTIVE.— To investigate morphologic and immunologic changes incited by CPI therapy in the upper gastrointestinal tract. DESIGN.— We compared the morphology and immune cell phenotype of gastric and duodenal biopsies from patients treated with anti-cytotoxic T-lymphocyte associated protein 4 (CTLA-4) or anti-programmed death receptor-1/programmed death ligand-1 (PD-1/PD-L1) antibodies with biopsies from patients with Helicobacter pylori gastritis, patients with celiac disease, and normal controls. RESULTS.— Gastric biopsies from patients on CPIs showed chronic gastritis mimicking H pylori gastritis. However, CPI gastritis demonstrated greater numbers of CD8+ intraepithelial lymphocytes, less lamina propria inflammation, fewer plasma cells and CD20+ B cells, fewer lymphoid aggregates, and reduced CD4:CD8 ratio in both the lamina propria and the epithelial layer. There were no differences between anti-CTLA-4 and anti-PD-1/PD-L1 gastritis, except for more lymphoid aggregates in anti-PD-1/PD-L1 gastritis. Duodenal biopsies from patients on CPIs revealed chronic duodenitis with villous blunting, mimicking celiac disease. Compared with celiac disease, CPI duodenitis demonstrated higher prevalence of neutrophilic infiltrates and erosions, increased lamina propria CD3 and CD8 T cells, and reduced CD4:CD8 ratio. Upper gastrointestinal biopsies were more inflamed than concomitant colonic biopsies in the majority of patients. CONCLUSIONS.— The morphologic and immunophenotypic distinctions between CPI-associated upper gastrointestinal injuries and common infectious and autoimmune diseases may provide useful discriminators when clinicians are confronted with gastric and duodenal inflammatory changes in patients receiving CPI therapy.
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Affiliation(s)
- Lina Irshaid
- From the Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Marie E Robert
- From the Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Xuchen Zhang
- From the Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
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35
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Andreyev HJN, Lalji A, Mohammed K, Muls ACG, Watkins D, Rao S, Starling N, Chau I, Cruse S, Pitkaaho V, Matthews J, Caley L, Pittordou V, Adams C, Wedlake L. The FOCCUS study: a prospective evaluation of the frequency, severity and treatable causes of gastrointestinal symptoms during and after chemotherapy. Support Care Cancer 2021; 29:1443-1453. [PMID: 32676853 PMCID: PMC7843552 DOI: 10.1007/s00520-020-05610-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The underlying mechanisms of chemotherapy-induced gastrointestinal (GI) symptoms are poorly researched. This study characterised the nature, frequency, severity and treatable causes for GI symptoms prospectively in patients undergoing chemotherapy for GI malignancy. METHODS Patients receiving chemotherapy for a GI malignancy were assessed pre-chemotherapy, then monthly for 1 year using the Gastrointestinal Symptom Rating Scale, a validated patient-reported outcome measure. Patients with new, troublesome GI symptoms were offered investigations to diagnose the cause(s). Their oncologist was alerted when investigations were abnormal. RESULTS A total of 241 patients, 60% male, median age 63 years (range 30-88), were enrolled; 122 patients were withdrawn, 93%, because of progressive disease or death. During the study, > 20% patients reported chronic faecal incontinence and > 10% reported moderate or severe problems with taste, dysphagia, belching, heartburn, early satiety, appetite, nausea, abdominal cramps, peri-rectal pain, rectal flatulence, borborygmi, urgency of defecation or tenesmus. Thirty percent reported continuing passage of hard stools and 30% on-going diarrhoea. Moderate or severe fatigue affected 40% participants at its peak and persisted in 15% at 1 year. Toxicity dictated change in chemotherapy for 13-29% patients/month. Common Terminology Criteria for Adverse Events underestimated gastrointestinal morbidity. Pre-chemotherapy screening identified previously undiagnosed pathology: exocrine pancreatic insufficiency (9%), vitamin B12 deficiency (12%) and thyroid dysfunction (20%). Patients often refused investigations to diagnose their chemotherapy-induced symptoms; however, for every three investigations performed, one treatable cause was diagnosed: particularly small intestinal bacterial overgrowth (54%), bile acid malabsorption (43%), previously not described after chemotherapy, and unsuspected urinary tract infection (17%). CONCLUSIONS Patients undergoing chemotherapy for GI malignancy commonly have difficult GI symptoms requiring active management which does not occur routinely. The underlying causes for these symptoms are often treatable or curable. Randomised trials are urgently needed to show whether timely investigation and treatment of symptoms improve quality of life and survival. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02121626.
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Affiliation(s)
- H Jervoise N Andreyev
- The Department of Gastroenterology, Lincoln County Hospital, United Lincolnshire Hospitals Trust, Greetwell Rd, Lincoln, LN2 5PT, UK.
- The Biomedical Research Centre, Nottingham Digestive Diseases Centre, The School of Medicine, University of Nottingham, Nottingham, UK.
| | - Amyn Lalji
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Kabir Mohammed
- Clinical Research and Development Department, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Ann C G Muls
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - David Watkins
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Sheela Rao
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Naureen Starling
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Ian Chau
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Sarah Cruse
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Ville Pitkaaho
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Jennifer Matthews
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Laura Caley
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Victoria Pittordou
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Carolyn Adams
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Linda Wedlake
- Royal Marsden Clinical Trials Unit Royal Marsden NHS Foundation Trust, Sutton, UK
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36
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Arora K, Zhang ML, Goiburú-Chenu MB, England J. Pathology of immune checkpoint inhibitor-induced injury of the gastrointestinal tract and hepatobiliary system. ACTA ACUST UNITED AC 2021. [DOI: 10.1016/j.mpdhp.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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37
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Riveiro-Barciela M, Trallero-Araguás E, Martínez-Valle F. Toxicities from immunotherapy: From clinical trials to real-world clinical practice. Med Clin (Barc) 2020; 155:541-547. [PMID: 32868034 DOI: 10.1016/j.medcli.2020.06.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 02/07/2023]
Abstract
In recent years, immunotherapy has become an important pillar of cancer treatment, with high response rates regardless of tumour histology or baseline mutations. However, immune activation associated with check-point inhibitors is not selective and a large variety of immune-related adverse events have been associated with anti-PD1, anti-PD-1/L-1 and anti-CTLA-4 agents. Though diagnosis and treatment of these toxicities have been established according to the recommendations from clinical trials and in line with the autoimmune disorders that they mimic, increasing real-world data is coming up showing that these adverse events may have differential characteristics and management, especially in terms of the use of corticoids, second-line treatments, salvage therapy for life-threatening cases and reintroduction of immunotherapy. Herein we present a comprehensive review of current recommendations and real-world data on the main immune-related adverse events of immunotherapy.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Fernando Martínez-Valle
- Systemic Autoimmune Diseases Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Dahiya DS, Wani F, Guidi JC, Kichloo A. Gastrointestinal Adverse Effects of Immunotherapeutic Agents: A Systematic Review. Gastroenterology Res 2020; 13:227-232. [PMID: 33447301 PMCID: PMC7781271 DOI: 10.14740/gr1340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/05/2020] [Indexed: 12/26/2022] Open
Abstract
The utilization of immunotherapy is increasing to the point of becoming the fifth pillar of management alongside surgical intervention, chemotherapy, radiotherapy and targeted therapy. However, gastrointestinal adverse effects and toxicities have been frequently cited with its use. As per literature, the most common adverse effect of immune checkpoint inhibitors is watery and non-bloody diarrhea. Adoptive cell therapy can lead to delayed, on-target but off-tumor adverse effects which are unknown and may be life-threatening. The use of anti-angiogenic monoclonal antibodies can lead to bowel perforations, whereas epidermal growth factor receptor inhibitors and anti-HER2 agents are frequently associated with diarrhea. Minimal adverse effects have been associated with therapeutic cancer vaccines; however, additional studies are needed to determine their efficacy and potential toxicities. To provide an in-depth review of the gastrointestinal side effects of immunotherapeutic agents, we performed a thorough literature search using multiple online search engines such as PubMed, Google Scholar and Ovid MEDLINE, along with a review of the guidelines from the United States Food and Drug Administration (FDA) and the Cancer Research Institute on immunotherapy. In this systematic review, we detail the gastrointestinal adverse effects of immunotherapy and describe their management. With the advent of newer immunotherapeutic agents and the consistent approval of current agents by FDA for a wide spectrum of cancers, it is vital for physicians to familiarize themselves with their adverse effects for prompt diagnosis and early intervention to decrease adverse outcomes.
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Affiliation(s)
| | - Farah Wani
- Department of Family Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Jean Claude Guidi
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Saginaw, MI, USA.,Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
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39
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Muehler A, Slizgi JR, Kohlhof H, Groeppel M, Peelen E, Vitt D. Clinical relevance of intestinal barrier dysfunction in common gastrointestinal diseases. World J Gastrointest Pathophysiol 2020; 11:114-130. [PMID: 33362939 PMCID: PMC7739114 DOI: 10.4291/wjgp.v11.i6.114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/07/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
The intestinal barrier is a complex and well-controlled physiological construct designed to separate luminal contents from the bowel wall. In this review, we focus on the intestinal barrier’s relationship with the host’s immune system interaction and the external environment, specifically the microbiome. The bowel allows the host to obtain nutrients vital to survival while protecting itself from harmful pathogens, luminal antigens, or other pro-inflammatory factors. Control over barrier function and the luminal milieu is maintained at the biochemical, cellular, and immunological level. However, disruption to this highly regulated environment can cause disease. Recent advances to the field have progressed the mechanistic understanding of compromised intestinal barrier function in the context of gastrointestinal pathology. There are numerous examples where bowel barrier dysfunction and the resulting interaction between the microbiome and the immune system has disease-triggering consequences. The purpose of this review is to summarize the clinical relevance of intestinal barrier dysfunction in common gastrointestinal and related diseases. This may help highlight the importance of restoring barrier function as a therapeutic mechanism of action in gastrointestinal pathology.
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40
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Isidro RA, Ruan AB, Gannarapu S, Raj D, Rahma O, Grover S, Srivastava A. Medication-specific variations in morphological patterns of injury in immune check-point inhibitor-associated colitis. Histopathology 2020; 78:532-541. [PMID: 32931028 DOI: 10.1111/his.14248] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022]
Abstract
AIMS A varied spectrum of histopathological changes has been associated with immune checkpoint inhibitor (ICI) colitis. This study was performed to evaluate the prevalence of different histopathological patterns of injury in patients with ICI colitis and their association with specific immune check-point inhibitors. METHODS AND RESULTS Biopsies from patients with clinically and histologically confirmed ICI colitis were reviewed blindly to determine the predominant pattern of injury and to quantitate discrete histological parameters using the Geboes score. Paneth cell metaplasia, intraepithelial lymphocytes, abnormal subepithelial collagen and degree of crypt epithelial apoptosis was also recorded. A total of 86 patients with ICI colitis (ipilimumab, n = 14; ipilimumab + nivolumab, n = 29; nivolumab, n = 20 and pembrolizumab, n = 23) were included. The patterns of injury identified included diffuse active colitis (n = 22), chronic active colitis (n = 22), lymphocytic colitis (LC, n = 16), collagenous colitis (CC, n = 14), graft-versus-host disease-like colitis (n = 7) and mixed colitis (n = 5). Patients on ipilimumab were more likely to have a diffuse active colitis pattern without features of chronicity (P < 0.01) and less likely to have LC (P < 0.05) compared to other ICIs. LC and CC were more common in patients on nivolumab and pembrolizumab relative to other groups (P < 0.05). Chronic active colitis was most frequent in nivolumab patients (P < 0.05), and these patients had received more ICI doses and had been on ICI treatment longer compared to other treatment groups. CONCLUSIONS ICI colitis should be considered in the differential diagnosis of all the common inflammatory patterns of colitis and shows medication specific differences in patterns of injury.
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Affiliation(s)
- Raymond A Isidro
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Swetha Gannarapu
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA
| | - Dhanya Raj
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA
| | - Osama Rahma
- Division of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Shilpa Grover
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA
| | - Amitabh Srivastava
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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41
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Wang M, Liang H, Wang W, Zhao S, Cai X, Zhao Y, Li C, Cheng B, Xiong S, Li J, He J, Liang W. Immune-related adverse events of a PD-L1 inhibitor plus chemotherapy versus a PD-L1 inhibitor alone in first-line treatment for advanced non-small cell lung cancer: A meta-analysis of randomized control trials. Cancer 2020; 127:777-786. [PMID: 33119182 DOI: 10.1002/cncr.33270] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/02/2020] [Accepted: 07/23/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The addition of chemotherapy to a programmed death 1/programmed death ligand 1 (PD-L1) inhibitor is a more effective option as a first-line treatment for advanced non-small cell lung cancer (NSCLC). It might also inhibit an overactive immune response and thereby reduce immune-related adverse events (irAEs). This meta-analysis assessed the rate of irAEs with a PD-(L)1 inhibitor plus chemotherapy (I+C) versus a PD-(L)1 inhibitor alone (I) and evaluated the indirect relative risk (RR) of I+C versus I. METHODS The protocol of this study was registered with PROSPERO (CRD42020139923). The pooled rates of irAEs at different grades were calculated by a single-arm meta-analysis weighted by sample size, and RRs were determined by direct meta-analysis and indirect treatment comparison. RESULTS Overall, I+C had a lower rate of grade 3 or higher irAEs than I (7.1% vs 10.6%; indirect RR, 0.516; 95% confidence interval [CI], 0.291-0.916), although irAEs of any grade were similar. The rate of pneumonitis with I+C was lower than the rate with I for any grade (5.9% vs 7.1%; indirect RR, 0.217; 95% CI, 0.080-0.588) and for grade 3 or higher. In the endocrine system, I+C was associated with a lower overall ratein comparison with I (16.1% vs 20.1%; indirect RR, 0.260; 95% CI, 0.120-0.564), whereas irAEs of the digestive system were similar with I+C and I. In other systems, I+C decreased the rate of skin reactions, including rash, in comparison with I (10.4% vs 12.9%; indirect RR, 0.474; 95% CI, 0.299-0.751). The rate of grade 3 or higher skin reactions (excluding rash) also decreased with I+C versus I (1.1% vs 2.0%) with an indirect RR of 0.158 (95% CI, 0.032-0.765), whereas other included irAEs were similar. CONCLUSIONS In comparison with a PD-(L)1 inhibitor alone, a combination with chemotherapy for the first-line treatment of NSCLC decreased the rates of most irAEs, such as pneumonitis and endocrine and skin reactions, and the overall rate. LAY SUMMARY In the first-line treatment of advanced non-small cell lung cancer (NSCLC), the addition of chemotherapy to a programmed death 1/programmed death ligand 1 (PD-(L)1) inhibitor is a more effective option. Adding chemotherapy might reduce immune-related adverse events (irAEs). Thus, this article assesses the rate of irAEs with a PD-(L)1 inhibitor plus chemotherapy (I+C) in comparison with a PD-(L)1 inhibitor alone (I) and evaluates the indirect relative risk (RR) with I+C versus I. The key finding is that in comparison with a PD-(L)1 inhibitor alone, a combination with chemotherapy for the first-line treatment of NSCLC decreases the rates of most irAEs, such as pneumonitis and endocrine and skin reactions, and the overall rate.
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Affiliation(s)
- Manting Wang
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China.,Nanshan School, Clinical Medicine Department, Guangzhou Medical University, Guangzhou, China
| | - Hengrui Liang
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Wei Wang
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Shen Zhao
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiuyu Cai
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of General Internal Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yi Zhao
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Caichen Li
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Bo Cheng
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Shan Xiong
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Jianfu Li
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Wenhua Liang
- Department of Thoracic Surgery and Oncology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory of Respiratory Disease, Guangzhou, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, China.,Guangzhou Institute of Respiratory Health, Guangzhou, China
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42
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Martins Lopes MS, Machado LM, Ismael Amaral Silva PA, Tome Uchiyama AA, Yen CT, Ricardo ED, Mutao TS, Pimenta JR, Shimba DS, Hanriot RM, Peixoto RD. Antibiotics, cancer risk and oncologic treatment efficacy: a practical review of the literature. Ecancermedicalscience 2020; 14:1106. [PMID: 33144874 PMCID: PMC7581329 DOI: 10.3332/ecancer.2020.1106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Indexed: 12/12/2022] Open
Abstract
Antibiotics have been extensively used to treat infectious diseases over the past century and have largely contributed to increased life expectancy over time. However, antibiotic use can impose profound and protracted changes to the diversity of the microbial ecosystem, affecting the composition of up to 30% of the bacterial species in the gut microbiome. By modifying human microbiota composition, antibiotics alter the action of several oncologic drugs, potentially leading to decreased efficacy and increased toxicities. Whether antibiotics interfere with cancer therapies or even increase the risk of cancer development has been under investigation, and no randomised trials have been conducted so far. The aim of the current review is to describe the possible effects of antibiotic therapies on different oncologic treatments, especially immunotherapies, and to explore the link between previous antibiotics use and the development of cancer.
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Affiliation(s)
| | | | | | | | - Cheng T Yen
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | | | | | | | | | - Renata D Peixoto
- Centro Paulista de Oncologia (Grupo Oncoclínicas), São Paulo, Brazil
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43
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Enteritis secondary to nivolumab, a growing cause of diarrhoea. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:620-621. [PMID: 32883540 DOI: 10.1016/j.gastrohep.2020.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/20/2020] [Accepted: 03/13/2020] [Indexed: 11/22/2022]
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44
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Mendo R, Figueiredo P, Mascarenhas L. Checkpoint Inhibitor-Induced Gastroduodenitis: An Unusual Manifestation. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:150-152. [PMID: 33791404 DOI: 10.1159/000509196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/20/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Rui Mendo
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Pedro Figueiredo
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal.,Department of Gastroenterology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Luís Mascarenhas
- Department of Pathology, Hospital da Luz Lisboa, Lisbon, Portugal
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45
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Dong S, Luo C, Hu X, Zhang J, Cai Q, Qian Y, Ran F, Ou W, Wang J, Huang Q, Ren T, Han G, Zhang F, Wei W, Liang X, Xu H, Wang S, Shi L, Wei S, Hu S. Expert Consensus for Treating Cancer Patients During the Pandemic of SARS-CoV-2. Front Oncol 2020; 10:1555. [PMID: 33014801 PMCID: PMC7462010 DOI: 10.3389/fonc.2020.01555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022] Open
Abstract
The sudden pandemic of SARS-Cov-2 (also known as novel coronavirus disease 2019, COVID-19) poses a severe threat to hundreds of millions of lives in the world. The complete cure of the virus largely relies on the immune system, which becomes particularly a challenge for the cancer subjects, whose immunity is generally compromised. However, in a constant evolving situation, the clinical data on the prevalence of SARS-Cov-2 for cancer patients is still limited. On top of a wide range of medical references and interim guidelines including CDC, NCI, ASCO, ESMO, NCCN, AACR, ESMO, and the National Health Commission of China, etc., we formed into a guideline based on our experience in our specialized cancer hospital in Wuhan, the originally endemic center of the virus. Furthermore, we formulated an expert consensus which was developed by all contributors from different disciplines after fully discussion based on our understanding and analysis of limited information of COVID-19. The consensus highlighted a multidisciplinary team diagnostic model with assessment of the balance between risks and benefits prior to treatment, individualizing satisfaction of patients' medical needs, and acceptability in ethics and patients' socio-economic conditions.
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Affiliation(s)
- Shuang Dong
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Chenggang Luo
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- The Cancer Quality Control Center of Hubei Province, Wuhan, China
- Department of Radiological Intervention, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuebo Hu
- Laboratory of Drug Discovery and Molecular Engineering, Department of Medicinal Plants, College of Plant Science and Technology, Huazhong Agricultural University, Wuhan, China
| | - Jing Zhang
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Qian Cai
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Yu Qian
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Fengming Ran
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Wuling Ou
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- The Cancer Quality Control Center of Hubei Province, Wuhan, China
| | - Jun Wang
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Qing Huang
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Tianhua Ren
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Guang Han
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Zhang
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- Department of Hepatobiliary and Pancreatic Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- The Administration of Cancer Clinical Trials and GCP, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Wei
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- The Cancer Quality Control Center of Hubei Province, Wuhan, China
- Radiotherapy Center, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinjun Liang
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Huiting Xu
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
| | - Sheng Wang
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- Department of Thoracic Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lulu Shi
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- The Cancer Quality Control Center of Hubei Province, Wuhan, China
- The Administration of Cancer Clinical Trials and GCP, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shaozhong Wei
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- The Cancer Quality Control Center of Hubei Province, Wuhan, China
- Department of Gastrointestinal Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Hu
- Department of Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Cancer Center, Wuhan, China
- The Office of Hubei Provincial Cancer Prevention, Wuhan, China
- The Cancer Quality Control Center of Hubei Province, Wuhan, China
- Department of Gastrointestinal Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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46
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Renga G, Bellet MM, Pariano M, Gargaro M, Stincardini C, D'Onofrio F, Mosci P, Brancorsini S, Bartoli A, Goldstein AL, Garaci E, Romani L, Costantini C. Thymosin α1 protects from CTLA-4 intestinal immunopathology. Life Sci Alliance 2020; 3:3/10/e202000662. [PMID: 32817121 PMCID: PMC7441522 DOI: 10.26508/lsa.202000662] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022] Open
Abstract
This study demonstrates that Tα1 protects mice from anti–CTLA-4–induced colitis and sustains its antitumor activity, thus suggesting that Tα1 may be used in combination protocols. The advent of immune checkpoint inhibitors has represented a major boost in cancer therapy, but safety concerns are increasingly being recognized. Indeed, although beneficial at the tumor site, unlocking a safeguard mechanism of the immune response may trigger autoimmune-like effects at the periphery, thus making the safety of immune checkpoint inhibitors a research priority. Herein, we demonstrate that thymosin α1 (Tα1), an endogenous peptide with immunomodulatory activities, can protect mice from intestinal toxicity in a murine model of immune checkpoint inhibitor–induced colitis. Specifically, Tα1 efficiently prevented immune adverse pathology in the gut by promoting the indoleamine 2,3-dioxygenase (IDO) 1–dependent tolerogenic immune pathway. Notably, Tα1 did not induce IDO1 in the tumor microenvironment, but rather modulated the infiltration of T-cell subsets by inverting the ratio between CD8+ and Treg cells, an effect that may depend on Tα1 ability to regulate the differentiation and chemokine expression profile of DCs. Thus, through distinct mechanisms that are contingent upon the context, Tα1 represents a plausible candidate to improve the safety/efficacy profile of immune checkpoint inhibitors.
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Affiliation(s)
- Giorgia Renga
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Marina M Bellet
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Marilena Pariano
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Marco Gargaro
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | | | - Fiorella D'Onofrio
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Paolo Mosci
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | | | - Andrea Bartoli
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Allan L Goldstein
- Department of Biochemistry and Molecular Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Enrico Garaci
- University San Raffaele and Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele, Rome, Italy
| | - Luigina Romani
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Claudio Costantini
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
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47
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Powell N, Ibraheim H, Raine T, Speight RA, Papa S, Brain O, Green M, Samaan MA, Spain L, Yousaf N, Hunter N, Eldridge L, Pavlidis P, Irving P, Hayee B, Turajlic S, Larkin J, Lindsay JO, Gore M. British Society of Gastroenterology endorsed guidance for the management of immune checkpoint inhibitor-induced enterocolitis. Lancet Gastroenterol Hepatol 2020; 5:679-697. [PMID: 32553146 DOI: 10.1016/s2468-1253(20)30014-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 12/15/2022]
Abstract
Immune checkpoint inhibitors are a novel class of cancer treatment that have improved outcomes for a subset of cancer patients. They work by antagonising inhibitory immune pathways, thereby augmenting immune-mediated antitumour responses. However, immune activation is not cancer-specific and often results in the activation of immune cells in non-cancer tissues, resulting in off-target immune-mediated injury and organ dysfunction. Diarrhoea and gastrointestinal tract inflammation are common and sometimes serious side-effects of this type of therapy. Prompt recognition of gastrointestinal toxicity and, in many cases, rapid institution of anti-inflammatory or biologic therapy (or both) is required to reverse these complications. Management of organ-specific complications benefits from multidisciplinary input, including engagement with gastroenterologists for optimal management of immune checkpoint inhibitor-induced enterocolitis. In this British Society of Gastroenterology endorsed guidance document, we have developed a consensus framework for the investigation and management of immune checkpoint inhibitor-induced enterocolitis.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/toxicity
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Agents, Immunological/toxicity
- Consensus
- Endoscopy/methods
- Endoscopy, Digestive System/methods
- Enterocolitis/chemically induced
- Enterocolitis/drug therapy
- Enterocolitis/metabolism
- Gastroenterology/organization & administration
- Gastrointestinal Diseases/chemically induced
- Gastrointestinal Diseases/diagnostic imaging
- Gastrointestinal Diseases/pathology
- Guidelines as Topic
- Humans
- Infliximab/therapeutic use
- Lactoferrin/metabolism
- Leukocyte L1 Antigen Complex/metabolism
- Neoplasms/drug therapy
- Patient Care Management/methods
- Societies, Medical/organization & administration
- Tumor Necrosis Factor-alpha/antagonists & inhibitors
- United Kingdom/epidemiology
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Affiliation(s)
- Nick Powell
- Division of Digestive Diseases, Faculty of Medicine, Imperial College London, UK; The Royal Marsden Hospital, London, UK.
| | - Hajir Ibraheim
- Division of Digestive Diseases, Faculty of Medicine, Imperial College London, UK; The Royal Marsden Hospital, London, UK
| | - Tim Raine
- Addenbrooke's Hospital, Cambridge University Teaching Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard A Speight
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Sophie Papa
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK; Department of Medical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Oliver Brain
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Michael Green
- Department of Histopathology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark A Samaan
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | | | | | - Polychronis Pavlidis
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; Centre for Inflammation and Cancer Immunology, King's College London, London, UK
| | - Peter Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King's College Hospital, London, UK
| | - Samra Turajlic
- The Royal Marsden Hospital, London, UK; Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | | | - James O Lindsay
- The Royal London Hospital, Barts Health NHS Trust, London, UK; Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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48
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Yoshimura K, Saku A, Karayama M, Inui N, Sugimura H, Suda T. Leucine-Rich α 2-Glycoprotein as a Potential Biomarker for Immune-related Colitis After Anti-PD-L1 Therapy: A Report of a Case Series. Clin Lung Cancer 2020; 21:e516-e522. [PMID: 32389505 DOI: 10.1016/j.cllc.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/29/2020] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Katsuhiro Yoshimura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan; Department of Tumor Pathology, Hamamatsu University School of Medicine, Hamamatsu, Japan.
| | - Aiko Saku
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan; Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masato Karayama
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Inui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan; Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Haruhiko Sugimura
- Department of Tumor Pathology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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49
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Peters MF, Choy AL, Pin C, Leishman DJ, Moisan A, Ewart L, Guzzie-Peck PJ, Sura R, Keller DA, Scott CW, Kolaja KL. Developing in vitro assays to transform gastrointestinal safety assessment: potential for microphysiological systems. LAB ON A CHIP 2020; 20:1177-1190. [PMID: 32129356 DOI: 10.1039/c9lc01107b] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Drug-induced gastrointestinal toxicities (DI-GITs) are among the most common adverse events in clinical trials. High prevalence of DI-GIT has persisted among new drugs due in part to the lack of robust experimental tools to allow early detection or to guide optimization of safer molecules. Developing in vitro assays for the leading GI toxicities (nausea, vomiting, diarrhoea, constipation, and abdominal pain) will likely involve recapitulating complex physiological properties that require contributions from diverse cell/tissue types including epithelial, immune, microbiome, nerve, and muscle. While this stipulation may be beyond traditional 2D monocultures of intestinal cell lines, emerging 3D GI microtissues capture interactions between diverse cell and tissue types. These interactions give rise to microphysiologies fundamental to gut biology. For GI microtissues, organoid technology was the breakthrough that introduced intestinal stem cells with the capability of differentiating into each of the epithelial cell types and that self-organize into a multi-cellular tissue proxy with villus- and crypt-like domains. Recently, GI microtissues generated using miniaturized devices with microfluidic flow and cyclic peristaltic strain were shown to induce Caco2 cells to spontaneously differentiate into each of the principle intestinal epithelial cell types. Second generation models comprised of epithelial organoids or microtissues co-cultured with non-epithelial cell types can successfully reproduce cross-'tissue' functional interactions broadening the potential of these models to accurately study drug-induced toxicities. A new paradigm in which in vitro assays become an early part of GI safety assessment could be realized if microphysiological systems (MPS) are developed in alignment with drug-discovery needs. Herein, approaches for assessing GI toxicity of pharmaceuticals are reviewed and gaps are compared with capabilities of emerging GI microtissues (e.g., organoids, organ-on-a-chip, transwell systems) in order to provide perspective on the assay features needed for MPS models to be adopted for DI-GIT assessment.
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Affiliation(s)
- Matthew F Peters
- Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Boston, USA.
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50
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Wang A, Xu Y, Fei Y, Wang M. The role of immunosuppressive agents in the management of severe and refractory immune-related adverse events. Asia Pac J Clin Oncol 2020; 16:201-210. [PMID: 32212243 DOI: 10.1111/ajco.13332] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 02/27/2020] [Indexed: 12/15/2022]
Abstract
The advent of immune checkpoint inhibitors has improved survival in some types of cancer and brought promising prospects to cancer immunotherapy. Despite their clinical benefits, significant off-target toxicities resulting from the immune system activation have been observed, namely immune-related adverse events (irAEs), which pose to clinicians a new challenge of optimal management. With steroids being the mainstay of current management of irAEs, immunosuppressive agents are especially indicated for severe or steroid-refractory cases, based on current immunopathophysiological knowledge and on extrapolations of treatment options for primary autoimmune disorders. This review focuses on the status and recent clinical progress of immunosuppressive agents in the management of severe and steroid-refractory irAEs.
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Affiliation(s)
- Anqi Wang
- Department of Rheumatology and Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunyun Fei
- Department of Rheumatology and Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengzhao Wang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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