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Park BJ, Warning AW, Akella SS. Checkpoint inhibitor-related myasthenia-myocarditis-myositis overlap syndrome in the orbit. Orbit 2024:1-7. [PMID: 38796779 DOI: 10.1080/01676830.2024.2351519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024]
Abstract
We report a series of three patients who developed checkpoint inhibitor-related myocarditis with orbital myositis and/or myasthenia gravis overlap syndrome, with varying degrees of severity. In all cases, checkpoint inhibitor therapy was immediately discontinued upon diagnosis and corticosteroids were initiated. While two patients achieved substantial recovery, one patient passed away on hospital day three. These cases underscore the critical need for prompt recognition of adverse events associated with immune checkpoint inhibitors.
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Affiliation(s)
- Benjamin Jinsung Park
- Department of Ophthalmology and Visual Science, The Ohio State University Wexner Medical Center and The Ohio State University Comprehensive Cancer Center - James Cancer Center and Solove Research Institute, Columbus, Ohio, USA
| | - Aaron W Warning
- Department of Ophthalmology and Visual Science, The Ohio State University Wexner Medical Center and The Ohio State University Comprehensive Cancer Center - James Cancer Center and Solove Research Institute, Columbus, Ohio, USA
| | - Sruti S Akella
- Department of Ophthalmology and Visual Science, The Ohio State University Wexner Medical Center and The Ohio State University Comprehensive Cancer Center - James Cancer Center and Solove Research Institute, Columbus, Ohio, USA
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2
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Shu X, Shao Y, Chen Y, Zeng C, Huang X, Wei R. Immune checkpoints: new insights into the pathogenesis of thyroid eye disease. Front Immunol 2024; 15:1392956. [PMID: 38817600 PMCID: PMC11137266 DOI: 10.3389/fimmu.2024.1392956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/01/2024] [Indexed: 06/01/2024] Open
Abstract
Thyroid eye disease (TED) is a disfiguring autoimmune disease characterized by changes in the orbital tissues and is caused by abnormal thyroid function or thyroid-related antibodies. It is the ocular manifestation of Graves' disease. The expression of thyroid-stimulating hormone receptor (TSHR) and the insulin-like growth factor-1 receptor (IGF-1 R) on the cell membrane of orbital fibroblasts (OFs) is responsible for TED pathology. Excessive inflammation is caused when these receptors in the orbit are stimulated by autoantibodies. CD34+ fibrocytes, found in the peripheral blood and orbital tissues of patients with TED, express immune checkpoints (ICs) like MHC II, B7, and PD-L1, indicating their potential role in presenting antigens and regulating the immune response in TED pathogenesis. Immune checkpoint inhibitors (ICIs) have significantly transformed cancer treatment. However, it can also lead to the occurrence of TED in some instances, suggesting the abnormality of ICs in TED. This review will examine the overall pathogenic mechanism linked to the immune cells of TED and then discuss the latest research findings on the immunomodulatory role of ICs in the development and pathogenesis of TED. This will offer fresh perspectives on the study of pathogenesis and the identification of potential therapeutic targets.
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Affiliation(s)
| | | | | | | | | | - Ruili Wei
- Department of Ophthalmology, Changzheng Hospital of Naval Medicine University, Shanghai, China
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3
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Fernández Jiménez-Ortiz H, Maroto Rodríguez B, Lapuente Monjas R, Sampedro Yáñez R, Sánchez Santos I, Toledano Fernández N. Iatrogenic affectation of ocular motility by immune checkpoint inhibitors. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2024; 99:158-164. [PMID: 38013131 DOI: 10.1016/j.oftale.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
Cancer therapy relies on new antitumoral drugs called immune checkpoint inhibitors (ICI), which produce long-lasting anti-tumor responses and lengthen survival, but cause autoimmune-type toxicity. The clinical characteristics induced by ICI are not well characterized to date and careful collection of clinical data is required to accurately define its safety profile. We conducted a literature search in the main clinical search engines to identify pharmacological ocular iatrogenic events of ICIs related to ocular motility. Four systematic reviews were found that included this type of ocular iatrogenesis as well as numerous isolated case reports. Reported adverse effects include: oculomotor paresis, optic neuropathy, optic atrophy, myastheniform syndromes, thyroid pseudo-orbitopathy, orbital apex syndrome, and hypophysitis. Most were managed without interruption or with partial interruption of cancer treatment. Aggressive systemic treatments were required for adequate management of ocular iatrogenic events. It is essential that the ophthalmologist become familiar with the new ICI oncological treatments, capable of causing severe and disabling motilidad ocular iatrogenesis for the patient. The communication of adverse effects and the report of the treatments used can help the most appropriate management of these patients. Research should be oriented towards complex differential diagnosis and to optimize decisions on cancer treatments.
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Affiliation(s)
| | - B Maroto Rodríguez
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - R Lapuente Monjas
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain.
| | - R Sampedro Yáñez
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | | | - N Toledano Fernández
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
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4
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Jebaraj AP, Etheridge TJ, Winegar BA, Marx DP. Ipilimumab-related orbitopathy: a case report. Orbit 2024; 43:100-104. [PMID: 35581713 DOI: 10.1080/01676830.2022.2074049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
Abstract
Ipilimumab, an immune checkpoint inhibitor used in the treatment of metastatic melanoma, can cause immune-related adverse events including rare ocular-related inflammation. This is a case of a 54-year-old man with metastatic melanoma and bilateral orbital inflammation associated with ipilimumab that occurred after drug rechallenge 6 years after initial orbital inflammation with ipilimumab use. Imaging revealed tendon-involving myositis. He was managed with intravenous corticosteroid and intravenous immunoglobulin therapy with improvement in his orbital inflammation. This case demonstrates the potential ocular effects of ipilimumab use, differentiation of ipilimumab-associated orbital inflammation from thyroid orbitopathy and management considerations to effectively reduce orbital inflammation.
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Affiliation(s)
- Abigail P Jebaraj
- Moran Eye Center, University of Utah John A., Salt Lake City, Utah, USA
| | - Tyler J Etheridge
- Moran Eye Center, University of Utah John A., Salt Lake City, Utah, USA
| | - Blair A Winegar
- Department of Radiology & Imaging Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Douglas P Marx
- Moran Eye Center, University of Utah John A., Salt Lake City, Utah, USA
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5
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Cieplińska K, Niedziela E, Kowalska A. Immunological Processes in the Orbit and Indications for Current and Potential Drug Targets. J Clin Med 2023; 13:72. [PMID: 38202079 PMCID: PMC10780108 DOI: 10.3390/jcm13010072] [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: 11/12/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Thyroid eye disease (TED) is an extrathyroidal manifestation of Graves' disease (GD). Similar to GD, TED is caused by an autoimmune response. TED is an autoimmune inflammatory disorder of the orbit and periorbital tissues, characterized by upper eyelid retraction, swelling, redness, conjunctivitis, and bulging eyes. The pathophysiology of TED is complex, with the infiltration of activated T lymphocytes and activation of orbital fibroblasts (OFs) and autoantibodies against the common autoantigen of thyroid and orbital tissues. Better understanding of the multifactorial pathogenesis of TED contributes to the development of more effective therapies. In this review, we present current and potential drug targets. The ideal treatment should slow progression of the disease with as little interference with patient immunity as possible. In the future, TED treatment will target the immune mechanism involved in the disease and will be based on a strategy of restoring tolerance to autoantigens.
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Affiliation(s)
| | - Emilia Niedziela
- Collegium Medicum, Jan Kochanowski University in Kielce, 25-317 Kielce, Poland; (E.N.); (A.K.)
- Department of Endocrinology, Holy Cross Cancer Center, 25-734 Kielce, Poland
| | - Aldona Kowalska
- Collegium Medicum, Jan Kochanowski University in Kielce, 25-317 Kielce, Poland; (E.N.); (A.K.)
- Department of Endocrinology, Holy Cross Cancer Center, 25-734 Kielce, Poland
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6
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Spadaro JZ, Kohli AA. Pathogenesis of Thyroid Eye Disease. Int Ophthalmol Clin 2023; 63:65-80. [PMID: 36963828 DOI: 10.1097/iio.0000000000000464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
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Martens A, Schauwvlieghe PP, Madoe A, Casteels I, Aspeslagh S. Ocular adverse events associated with immune checkpoint inhibitors, a scoping review. J Ophthalmic Inflamm Infect 2023; 13:5. [PMID: 36811715 PMCID: PMC9947214 DOI: 10.1186/s12348-022-00321-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/11/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have become an important part of the treatment of multiple cancers, especially for advanced melanoma and non-small cell lung cancer. Some tumors are capable of escaping immunosurveillance by stimulating checkpoints on T-cells. ICIs prevent activation of these checkpoints and thereby stimulate the immune system and indirectly the anti-tumor response. However, the use of ICIs is associated with various adverse events. Ocular side effects are rare but may have a major impact on the quality of life of the patient. METHODS A comprehensive literature search of the medical databases Web of Science, Embase and PubMed was performed. Articles that provided a comprehensive description of a case report containing 1) cancer patient(s) treated with (a combination of) immune checkpoint inhibitors, and 2) assessed occurrence of ocular adverse events, were included. A total of 290 case reports were included. RESULTS Melanoma (n = 179; 61.7%) and lung cancer (n = 56; 19.3%) were the most frequent reported malignancies. The primary used ICIs were nivolumab (n = 123; 42.5%) and ipilimumab (n = 116; 40.0%). Uveitis was most the common adverse event (n = 134; 46.2%) and mainly related to melanoma. Neuro-ophthalmic disorders, including myasthenia gravis and cranial nerve disorders, were the second most common adverse events (n = 71; 24.5%), mainly related to lung cancer. Adverse events affecting the orbit and the cornea were reported in 33 (11.4%) and 30 cases (10.3%) respectively. Adverse events concerning the retina were reported in 26 cases (9.0%). CONCLUSION The aim of this paper is to provide an overview of all reported ocular adverse events related to the use of ICIs. The insights retrieved from this review might contribute to a better understanding of the underlying mechanisms of these ocular adverse events. Particularly, the difference between actual immune-related adverse events and paraneoplastic syndromes might be relevant. These findings might be of great value in establishing guidelines on how to manage ocular adverse events related to ICIs.
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Affiliation(s)
- A. Martens
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - P. P. Schauwvlieghe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - A. Madoe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - I. Casteels
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - S. Aspeslagh
- grid.411326.30000 0004 0626 3362Department of Medical Oncology, University Hospital Brussels, Brussels, Belgium
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Wright JJ, Johnson DB. APPROACH TO THE PATIENT WITH IMMUNE CHECKPOINT INHIBITOR-ASSOCIATED ENDOCRINE DYSFUNCTION. J Clin Endocrinol Metab 2022; 108:1514-1525. [PMID: 36481794 PMCID: PMC10188314 DOI: 10.1210/clinem/dgac689] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors (ICI) are cancer therapies that are approved in at least 19 different cancers. They function by stimulating immune cell responses against cancer, and their toxicities comprise a host of autoinflammatory syndromes that may impact any organ system. Endocrine toxicities occur in as high as 25-50% of ICI recipients, depending on the treatment regimen used. These toxicities vary in severity from mild, asymptomatic cases of subclinical hypothyroidism to severe, fatal cases of adrenal crisis, thyroid dysfunction, or diabetic ketoacidosis. Thus, timely recognition and treatment is critical. Herein, we present clinical cases of ICI-induced thyroid dysfunction, hypophysitis, and insulin-dependent diabetes mellitus. We use these cases to discuss the screening, diagnosis, and management of ICI-associated endocrine dysfunction.
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Affiliation(s)
- Jordan J Wright
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Douglas B Johnson
- Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Ocular Inflammation Induced by Immune Checkpoint Inhibitors. J Clin Med 2022; 11:jcm11174993. [PMID: 36078923 PMCID: PMC9456546 DOI: 10.3390/jcm11174993] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Ocular immunotherapy-related adverse events (IRAEs), although rare, can be sight-threatening. Our objective was to analyze ocular IRAEs diagnosed in France from the marketing of immune checkpoint inhibitors (ICPIs) until June 2021 and to review the literature. We collected the cases of 28 patients (36 ocular IRAEs), occurring after an average of 17 weeks (±19). Forty-six percent of patients were treated for metastatic melanoma. Anti-PD1 agents were responsible for 57% of the IRAEs. Anterior uveitis was the most common (44%), followed by panuveitis (28%). Of 25 uveitis cases, 80% were bilateral and 60% were granulomatous. We found one case with complete Vogt-Koyanagi–Harada syndrome and one case of birdshot retinochoroidopathy. The other IRAEs were eight ocular surface disorders, one optic neuropathy, and one inflammatory orbitopathy. Seventy percent of the IRAEs were grade 3 according to the common terminology of AEs. ICPIs were discontinued in 60% of patients and 50% received local corticosteroids alone. The literature review included 230 uveitis cases, of which 7% were granulomatous. The distributions of ICPIs, cancer, and type of uveitis were similar to our cohort. Ocular IRAEs appeared to be easily controlled by local or systemic corticosteroids and did not require routine discontinuation of ICPIs. Further work is still warranted to define the optimal management of ocular IRAEs.
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Yuen KCJ, Samson SL, Bancos I, Gosmanov AR, Jasim S, Fecher LA, Weber JS. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGY (AACE) DISEASE STATE CLINICAL REVIEW EVALUATION AND MANAGEMENT OF IMMUNE CHECKPOINT INHIBITOR-MEDIATED ENDOCRINOPATHIES: A PRACTICAL CASE-BASED CLINICAL APPROACH. Endocr Pract 2022; 28:719-731. [PMID: 35477029 DOI: 10.1016/j.eprac.2022.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this case-based clinical review is to provide a practical approach for clinicians regarding the management of patients with immune checkpoint inhibitor (ICI)-mediated endocrinopathies. METHODS A literature search was conducted using PubMed, Embase and Scopus, and appropriate keywords. The discussions and strategies for diagnosis and management of ICI-mediated endocrinopathies are based on evidence available from prospective randomized clinical studies, cohort studies, cross-sectional studies, case-based studies, and expert consensus. RESULTS Immunotherapy with ICIs has transformed the treatment landscape of diverse cancer types, but frequently results in immune-mediated endocrinopathies that can cause acute and persistent morbidity, and rarely, death. The patterns of endocrinopathies differ between inhibitors of the CTLA-4 and PD-1/PD-L1 pathways, but most often involve the thyroid and pituitary glands. Less common but important presentations include insulin-deficient diabetes mellitus, primary adrenal insufficiency, primary hypoparathyroidism, central diabetes insipidus, primary hypogonadism, and pancreatitis with or without subsequent progression to diabetes or exocrine insufficiency. CONCLUSION In recent years, with increasing numbers of cancer patients being treated with ICIs, more clinicians in a variety of specialties are called upon to diagnose and treat ICI-mediated endocrinopathies. Herein, we review case scenarios of various clinical manifestations, and emphasize the need for a high index of clinical suspicion by all clinicians caring for these patients including endocrinologists, oncologists, primary care providers, and emergency department physicians. We also provide diagnostic and therapeutic approaches for ICI-induced endocrinopathies, and we propose that patients on ICI-therapy be evaluated and treated in a multidisciplinary team in collaboration with endocrinologists.
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Affiliation(s)
- Kevin C J Yuen
- Co-Chair of Task Force; Professor of Medicine, Department of Medicine, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona.
| | - Susan L Samson
- Co-Chair of Task Force; Senior Associate Consultant, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Jacksonville, Florida
| | - Irina Bancos
- Associate Professor of Medicine; Associate Program Director, Endocrinology Fellowship Program, Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, MN
| | - Aidar R Gosmanov
- Professor of Medicine, Division of Endocrinology, Albany Medical College; Chief, Endocrinology Section, Stratton VAMC, Albany, NY
| | - Sina Jasim
- Associate Professor of Medicine, Washington University in St. Louis, School of Medicine, Division of Endocrinology, Metabolism and Lipid Research, St. Louis, Missouri
| | - Leslie A Fecher
- ASCO Representative, Associate Professor of Medicine and Dermatology, University of Michigan, Rogel Cancer Center, Ann Arbor, Michigan
| | - Jeffrey S Weber
- ASCO Representative, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York
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11
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Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target two key signalling pathways related to T cell activation and exhaustion, by binding to and inhibiting cytotoxic T lymphocyte antigen 4 (CTLA4) or PD1 and its ligand PDL1. ICIs, such as nivolumab, pembrolizumab and ipilimumab, are approved for the treatment of numerous and diverse cancer types, in various combination regimens, and are now an established cornerstone of cancer therapeutics. Toxicities induced by ICIs are autoimmune in nature and are referred to as immune-related adverse events (irAEs); these events can affect any organ system in an unpredictable fashion. Importantly, irAEs can manifest as endocrinopathies involving the thyroid (hypothyroidism or thyrotoxicosis), pituitary (hypophysitis), adrenal glands (adrenal insufficiency) and pancreas (diabetes mellitus). These events are a frequent source of acute and persistent morbidity in patients treated with ICIs and can even be fatal. Over the past few years, there has been a growing understanding of the underlying pathogenesis of irAEs that has led to the development of more effective management strategies. Herein, we review the current understanding of the pathobiology, clinical manifestations and treatment approaches to endocrine toxicities arising from ICIs.
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Affiliation(s)
- Jordan J Wright
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Alvin C Powers
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA.
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Mai K, Fassnacht M, Führer-Sakel D, B. Honegger J, M. Weber M, Kroiss M. The Diagnosis and Management of Endocrine Side Effects of Immune Checkpoint Inhibitors. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0143. [PMID: 33724917 PMCID: PMC8378258 DOI: 10.3238/arztebl.m2021.0143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/01/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The immunologically mediated side effects of immune checkpoint inhibitors (CPI) often involve the endocrine system as well, and they can even be fatal, as in the case of unrecognized hypophysitis. Distinguishing such side effects from tumor-related changes is often difficult, because their clinical features can be nonspecific. METHODS This review is based on publications retrieved by a selective search in PubMed, with special attention to international recommendations. RESULTS Depending on their target molecules, the CPI now in use differ from one another in the incidence of side effects such as autoimmune thyroid disease (4-16%), hypophysitis (0.1- 18%), adrenalitis (0.7-8%), and autoimmune diabetes mellitus (0.5-2%). The typical clinical warning signs and laboratory constellations of hypophysitis include exhaustion, hyponatremia, and headache. Hypo- and hyperthyroidism and primary adrenocortical insufficiency likewise have nonspecific manifestations. Autoimmune diabetes mellitus often takes a fulminant course. Patients being treated with CPI should be monitored at close intervals, at least as frequently as the administration of the drug, so that endocrine side effects can be recognized in time. In case of doubt, glucocorticoid supplementation should be given whenever hypocortisolism is suspected, even before endocrine evaluation is completed and the results are available. Interrupting or discontinuing CPI treatment is rarely indicated. CONCLUSION With the increasing number of patients being treated with CPI, more and more physicians from a wide variety of specialties, not necessarily working in specialized centers, now have to consider immunologically mediated endocrine side effects in the differential diagnosis, and treat them properly when they arise. These things should be done in collaboration with endocrinologists. The ongoing study of such side effects of the CPI now in use, and of those that will be introduced in the future, is important and will lead to improved understanding.
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Affiliation(s)
- Knut Mai
- Department of Endocrinology, Diabetes and Nutrition, Charité–Universitätsmedizin Berlin: Prof. Dr. med. Knut Mai
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University of Würzburg, University Hospital Würzburg, Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
| | - Dagmar Führer-Sakel
- Department of Endocrinology, Diabetology and Metabolism, Essen University Hospital, University of Duisburg-Essen: Prof. Dr. med. Dr. rer. nat. Dagmar Führer-Sakel
| | - Jürgen B. Honegger
- Department of Neurosurgery, Tübingen University Hospital: Prof. Dr. med. Jürgen B. Honegger
| | - Matthias M. Weber
- Department of Internal Medicine I, Endocrinology, Johannes Gutenberg University Hospital Mainz: Prof. Dr. med. Matthias M. Weber
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University of Würzburg, University Hospital Würzburg, Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Department of Internal Medicine IV, Ludwig-Maximilians-University Munich: Prof. Dr. med.Dr. rer. nat. Matthias Kroiss
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Peiffert M, Cugnet-Anceau C, Dalle S, Chikh K, Assaad S, Disse E, Raverot G, Borson-Chazot F, Abeillon-du Payrat J. Graves' Disease during Immune Checkpoint Inhibitor Therapy (A Case Series and Literature Review). Cancers (Basel) 2021; 13:cancers13081944. [PMID: 33920721 PMCID: PMC8073133 DOI: 10.3390/cancers13081944] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 02/08/2023] Open
Abstract
Thyrotoxicosis is an adverse event associated with immune checkpoint inhibitors (ICPis) that occurs in 0.6 to 3.2% of treated patients, depending on ICPi class. Presentation usually consists of a biphasic thyroiditis with transient thyrotoxicosis and secondary hypothyroidism. ICPi-induced Graves' disease (GD), due to the stimulating activity of TSH-receptor autoantibodies (TRAb), is extremely rare. The aim of this retrospective study was to describe the characteristics and evolution of GD during ICPi therapy. Five among 243 patients followed for ICPi-induced thyrotoxicosis showed TRAb positivity (2% of the cohort). GD occurred quickly after initiation of ICPis; its course was typical for two patients, with prolonged requirement for antithyroid drug treatment (ATD). The three other patients experienced biphasic thyroiditis with secondary hypothyroidism requiring long-term substitution. Three other patients had a diagnosis of GD before starting ICPis; they evolved toward hypothyroidism with early cessation of ATD and long-term substitution treatment during ICPi treatment. None developed significant Graves' orbitopathy. ICPi treatment was not interrupted for thyroid dysfunction. In conclusion, GD is a rare, immune-related adverse event of ICPis with an unusual course and frequent evolution to biphasic thyroiditis. In the case of ICPi-induced thyrotoxicosis in the presence of TRAb, observing the spontaneous evolution and performing a scintigraphy are useful before starting ATD treatment. Pre-existing GD is not exacerbated by ICPis and tends to evolve towards hypothyroidism. ICPi treatment can be maintained with adequate biochemical surveillance.
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Affiliation(s)
- Mathilde Peiffert
- Faculté de Médecine, Université Lyon 1, 69008 Lyon, France; (S.D.); (K.C.); (E.D.); (G.R.); (F.B.-C.)
- Fédération d’Endocrinologie, Hôpital Louis Pradel, Groupement Hospitalier Est, Hospices Civils de Lyon, 69500 Bron, France
- Correspondence: (M.P.); (J.A.-d.P.); Tel.: +33-4-27-85-66-66 (J.A.-d.P.)
| | - Christine Cugnet-Anceau
- Service d’Endocrinologie-Diabète-Nutrition, Hôpital Lyon Sud, Hospices Civils de Lyon, 69310 Pierre-Bénite, France;
- ImmuCare, Institut de Cancérologie, Hospices Civils de Lyon, 69002 Lyon, France
| | - Stephane Dalle
- Faculté de Médecine, Université Lyon 1, 69008 Lyon, France; (S.D.); (K.C.); (E.D.); (G.R.); (F.B.-C.)
- ImmuCare, Institut de Cancérologie, Hospices Civils de Lyon, 69002 Lyon, France
- Service de Dermatologie, Hôpital Lyon Sud, Hospices Civils de Lyon, 69310 Pierre-Bénite, France
| | - Karim Chikh
- Faculté de Médecine, Université Lyon 1, 69008 Lyon, France; (S.D.); (K.C.); (E.D.); (G.R.); (F.B.-C.)
- Centre de Biologie Sud, Hôpital Lyon Sud, Hospices Civils de Lyon, 69310 Pierre-Bénite, France
| | - Souad Assaad
- Tox’imm, Centre Léon Bérard, 69008 Lyon, France;
- Service d’Hématologie et Médecine Interne, Centre Léon Berard, 69008 Lyon, France
| | - Emmanuel Disse
- Faculté de Médecine, Université Lyon 1, 69008 Lyon, France; (S.D.); (K.C.); (E.D.); (G.R.); (F.B.-C.)
- Service d’Endocrinologie-Diabète-Nutrition, Hôpital Lyon Sud, Hospices Civils de Lyon, 69310 Pierre-Bénite, France;
- INSERM U1060, INRA 1397, INSA Lyon, Centre de Recherche en Nutrition Humaine Rhône-Alpes (CRNH RA), CarMeN Laboratory, 69310 Pierre-Bénite, France
| | - Gérald Raverot
- Faculté de Médecine, Université Lyon 1, 69008 Lyon, France; (S.D.); (K.C.); (E.D.); (G.R.); (F.B.-C.)
- Fédération d’Endocrinologie, Hôpital Louis Pradel, Groupement Hospitalier Est, Hospices Civils de Lyon, 69500 Bron, France
- INSERM U1052, CNRS, UMR5286, Cancer Research Center of Lyon, 69008 Lyon, France
| | - Françoise Borson-Chazot
- Faculté de Médecine, Université Lyon 1, 69008 Lyon, France; (S.D.); (K.C.); (E.D.); (G.R.); (F.B.-C.)
- Fédération d’Endocrinologie, Hôpital Louis Pradel, Groupement Hospitalier Est, Hospices Civils de Lyon, 69500 Bron, France
| | - Juliette Abeillon-du Payrat
- Fédération d’Endocrinologie, Hôpital Louis Pradel, Groupement Hospitalier Est, Hospices Civils de Lyon, 69500 Bron, France
- ImmuCare, Institut de Cancérologie, Hospices Civils de Lyon, 69002 Lyon, France
- Correspondence: (M.P.); (J.A.-d.P.); Tel.: +33-4-27-85-66-66 (J.A.-d.P.)
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Goyal I, Pandey MR, Sharma R, Chaudhuri A, Dandona P. The side effects of immune checkpoint inhibitor therapy on the endocrine system. Indian J Med Res 2021; 154:559-570. [PMID: 35435341 PMCID: PMC9205006 DOI: 10.4103/ijmr.ijmr_313_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a relatively newer class of drugs approved for the treatment of malignancies such as melanoma, renal, bladder and lung cancer. Immune-related adverse events (IrAEs) involving the endocrine system are a common side effect of these drugs. The spectrum of endocrine adverse events varies by the drug class. Cytotoxic T-lymphocyte–associated antigen-4 inhibitors commonly cause hypophysitis/hypopituitarism, whereas the incidence of thyroid disease is higher with programmed cell death (PD)-1/ ligand (PD-L) protein 1 inhibitors. The focus of this review is to describe the individual endocrinopathies with their possible mechanisms, signs and symptoms, clinical assessment and disease management. Multiple mechanisms of IrAEs have been described in literature including type II/IV hypersensitivity reactions and development of autoantibodies. Patients with pre-existing autoimmune endocrine diseases can have disease exacerbation following ICI therapy rather than de novo IrAEs. Most of the endocrinopathies are relatively mild, and timely hormone replacement therapy allows continuation of ICIs. However, involvement of the pituitary–adrenal axis could be life-threatening if not recognized. Corticosteroids are helpful when the pituitary–adrenal axis is involved. In cases of severe endocrine toxicity (grade 3/4), ICIs should be temporarily discontinued and can be restarted after adequate hormonal therapy. Endocrinologists and general internists need to be vigilant and maintain a high degree of awareness for these adverse events.
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Affiliation(s)
- Itivrita Goyal
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
| | - Manu Raj Pandey
- Department of Hematology & Oncology, State University of New York at Buffalo; Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Rajeev Sharma
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo; Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Ajay Chaudhuri
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
| | - Paresh Dandona
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
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15
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Anderson B, Morganstein DL. Endocrine toxicity of cancer immunotherapy: clinical challenges. Endocr Connect 2021; 10:R116-R124. [PMID: 33544091 PMCID: PMC8052567 DOI: 10.1530/ec-20-0489] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/04/2021] [Indexed: 12/15/2022]
Abstract
Immune checkpoint inhibitors are now widely used in the treatment of multiple cancers. The major toxicities of these treatments are termed immune-related adverse events and endocrine dysfunction is common. Thyroid disease, hypopituitarism and a form of diabetes resembling type 1 diabetes are now all well described, with different patterns emerging with different checkpoint inhibitors. We review the presentation and management of the common endocrine immune-related adverse events, and discuss a number of recent advances in the understanding of these important, potentially life threatening toxicities. We also discuss some remaining dilemmas in management.
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Affiliation(s)
- Bliss Anderson
- Department of Endocrinology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Daniel L Morganstein
- Department of Endocrinology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Correspondence should be addressed to D L Morganstein:
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Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the field of oncology by modulating the immune cell-cancer cell interaction and thereby promoting immune system disinhibition in order to target several types of malignancies. There are three classes of immune checkpoint inhibitors (ICIs): anti-cytotoxic T-lymphocyte associated antigen 4 (CTLA-4), anti-programmed cell death protein-1 (PD-1), and anti-programmed cell death ligand-1 (PD-L1).It is not uncommon for physicians across all specialties to encounter a patient with a history of malignancy and ICI exposure, necessitating familiarity with their potential complications. In this review article, we discuss the most common immune-related adverse events (irAEs) pertaining to the central and peripheral nervous systems and their potential afferent and efferent neuro-ophthalmic manifestations. Early recognition and treatment of these irAEs, and discontinuation of the offending ICI are all critical steps to prevent morbidity and mortality.
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Affiliation(s)
- Loulwah Mukharesh
- Department of Ophthalmology, Massachusetts Eye & Ear/Harvard Medical School, Boston, MA, USA
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye & Ear/Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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17
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Alba-Linero C, Alba E. Ocular side effects of checkpoint inhibitors. Surv Ophthalmol 2021; 66:951-959. [PMID: 33440195 DOI: 10.1016/j.survophthal.2021.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 01/06/2023]
Abstract
The incidence and impact of ocular side effects in patients treated with checkpoint inhibitors are not clearly defined. We reviewed prospective phase III clinical trials of checkpoint inhibitors applied in lung cancer, renal cell cancer, and melanoma. Case reports of the occurrence of ocular toxicities in patients receiving immune checkpoint inhibitors were also included. Of the 35 articles corresponding to phase III clinical trials with checkpoint inhibitors, ocular toxicity was described in four. Forty-six clinical cases of ocular toxicity after therapy with checkpoint inhibitors have been reported. The most frequently described ocular toxicities are uveitis, inflammatory orbital disease, and alterations of the ocular surface. Ocular toxicity is underestimated in checkpoint inhibitors clinical trials. Early ophthalmic examination and treatment with corticosteroids may improve the visual prognosis in these patients.
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Affiliation(s)
- Carmen Alba-Linero
- Hospital Regional Universitario Málaga, Málaga, Spain; Departamento Oftalmología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain.
| | - Emilio Alba
- Unidad de gestión clínica (UGI) Oncología Médica Hospital Regional y Universitario de Málaga, Instituto de Investigación de Biotecnología de Málaga (IBIMA), Málaga, Spain
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18
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Considerations for Use of Immune Checkpoint Inhibitors in Cancer Therapy for Patients with Co-Existing Thyroid Eye Disease. Ophthalmol Ther 2020; 10:5-12. [PMID: 33146864 PMCID: PMC7886920 DOI: 10.1007/s40123-020-00317-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/19/2020] [Indexed: 02/08/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionised the field of oncology. While most ICIs are well-tolerated, severe and fatal immune-related adverse events (irAEs) have been documented, likely related to the strengthened immunity harnessed by ICIs against tumours. Endocrinopathies are some of the most common irAEs, with both hypothyroidism and hyperthyroidism encountered after ICI use. As such, patients with pre-existing autoimmune conditions, such as Graves' disease (GD) with clinically active thyroid eye disease (TED), are excluded from most clinical trials studying ICIs due to concerns of exacerbating pre-existing autoimmune conditions or of increasing the potential for irAE development. The limited information currently available on the safety and efficacy of ICIs in this population poses a clinical challenge for oncologists. The objective of this commentary is to highlight these challenges and provide treatment recommendations pertaining to two specific cohorts of patients with GD, namely GD patients with minimal eye complications and GD patients with previous TED who underwent radiotherapy, surgery or pulse methylprednisolone and whose disease is now quiescent, and to patients with subclinical autoimmune thyroid disease.
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19
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El Sabbagh R, Azar NS, Eid AA, Azar ST. Thyroid Dysfunctions Due to Immune Checkpoint Inhibitors: A Review. Int J Gen Med 2020; 13:1003-1009. [PMID: 33177863 PMCID: PMC7650809 DOI: 10.2147/ijgm.s261433] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/01/2020] [Indexed: 11/23/2022] Open
Abstract
Aim Immune checkpoint inhibitors are anti-cancer drugs associated with adverse events that result from releasing the immune system against self-antigens while attacking cancer cells. Thyroid dysfunctions are among the most common associated adverse events. Materials and Methods We conducted a systematic search of the literature in 2 databases: PubMed and Medline. Articles that reported thyroid adverse events of immune checkpoint inhibitors were reviewed. Thyroid disorders include hyperthyroidism and hypothyroidism and are most commonly seen with programmed cell death protein 1 and programmed death-ligand 1 inhibitors. Conclusions Thyroid disorders are common side effects seen with check point inhibitors and are treated, depending on the clinical situation, by adequate hormonal replacement, thionamides, corticosteroids or observation only. The use of high dose corticosteroids has not been established as a treatment of thyroid toxicities. Thyroid function tests screening should be a part of baseline laboratory testing of all patients undergoing treatment with immune checkpoint inhibitors.
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Affiliation(s)
- Rawaa El Sabbagh
- Division of Endocrinology and Metabolism, American University of Beirut, Beirut, Lebanon
| | - Nadim S Azar
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.,Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Assaad A Eid
- Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Sami T Azar
- Division of Endocrinology and Metabolism, American University of Beirut, Beirut, Lebanon
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20
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Yu CW, Yau M, Mezey N, Joarder I, Micieli JA. Neuro-ophthalmic Complications of Immune Checkpoint Inhibitors: A Systematic Review. Eye Brain 2020; 12:139-167. [PMID: 33173368 PMCID: PMC7648547 DOI: 10.2147/eb.s277760] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) are novel cancer therapies that may be associated with immune-related adverse events (IRAEs) and come to the attention of neuro-ophthalmologists. This systematic review aims to synthesize the reported ICI-associated IRAEs relevant to neuro-ophthalmologists to help in the diagnosis and management of these conditions. METHODS A systematic review of the literature indexed by MEDLINE, Embase, CENTRAL, and Web of Science databases was searched from inception to May 2020. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Primary studies on ICIs and neuro-ophthalmic complications were included. Outcomes included number of cases and incidence of neuro-ophthalmic IRAEs. RESULTS Neuro-ophthalmic complications of ICIs occurred in 0.46% of patients undergoing ICI and may affect the afferent and efferent visual systems. Afferent complications include optic neuritis (12.8%), neuroretinitis (0.9%), and giant cell arteritis (3.7%). Efferent complications include myasthenia gravis (MG) (45.0%), thyroid-like eye disease (11.9%), orbital myositis (13.8%), general myositis with ptosis (7.3%), internuclear ophthalmoplegia (0.9%), opsoclonus-myoclonus-ataxia syndrome (0.9%), and oculomotor nerve palsy (0.9%). Pembrolizumab was the most common causative agent for neuro-ophthalmic complications (32.1%). Mortality was highest for MG (19.8%). Most patients (79.8%) experienced improvement or complete resolution of neuro-ophthalmic symptoms due to cessation of ICI and immunosuppression with systemic corticosteroids. CONCLUSION While incidence of neuro-ophthalmic IRAEs is low, clinicians involved in the care of cancer patients must be aware of their presentation to facilitate prompt recognition and management. Collaboration between oncology and neuro-ophthalmology teams is required to effectively manage patients and reduce morbidity and mortality.
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Affiliation(s)
- Caberry W Yu
- Faculty of Medicine, Queen’s University, Kingston, Canada
| | - Matthew Yau
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Natalie Mezey
- Faculty of Medicine, Queen’s University, Kingston, Canada
| | - Ishraq Joarder
- Faculty of Science, University of Toronto, Scarborough, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences and Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
- Kensington Vision and Research Centre, Toronto, Canada
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21
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Eikenberry J, Harris A, Torabi R, Lang M, Denney D, Verticchio Vercellin A, Siesky B. Ocular side effects of target therapy and immunotherapy in patients with cutaneous malignant melanoma. Eur J Ophthalmol 2020; 31:1391-1398. [PMID: 32476450 DOI: 10.1177/1120672120930688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To examine the nature and frequency of ocular side effects due to systemic target therapy with BRAF and MEK inhibitors as well as immunotherapy with cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death 1 (PD-1) monoclonal antibodies used in the treatment of cutaneous malignant melanoma (CMM). DESIGN While proven effective in cancer treatment, target therapy and immunotherapy have been associated with ocular side effects likely due to their ability to alter the immune privilege of the eye. We conducted a retrospective chart review of patients undergoing target and immunotherapy for CMM and documented all associated eye findings. METHODS We reviewed the records of 34 patients receiving target and immunotherapy for CMM who were examined in the academic ophthalmology clinic between 2012 and 2017. RESULTS Ocular side effects were present in 41.1% of patients in this study with 14.7% presenting with uveitis. Patients undergoing therapy with either vemurafenib only or dabrafenib/trametinib combination therapies comprised 70.5% of the study cohort. Ocular side effects occurred in 45.5% and 46.1% of patients on vemurafenib and dabrafenib/trametinib combination therapy, respectively. About 47.5% of males presented with ocular side effects compared to 30.5% of females. Notably, 13/14 patients with ocular symptoms recovered. CONCLUSION This study highlights the frequency of ocular side effects in patients treated with target therapy and immunotherapy for CMM and shows that symptom resolution can be effectively achieved with proper ophthalmic care. Further research is required to answer whether cessation of these therapies is mandatory during ophthalmic treatment.
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Affiliation(s)
- Jennifer Eikenberry
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alon Harris
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Rana Torabi
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Matthew Lang
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Derek Denney
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alice Verticchio Vercellin
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA.,University of Pavia, Pavia, Italy.,IRCCS-Fondazione Bietti, Rome, Italy
| | - Brent Siesky
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
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22
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23
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Bhattacharya S, Goyal A, Kaur P, Singh R, Kalra S. Anticancer Drug-induced Thyroid Dysfunction. EUROPEAN ENDOCRINOLOGY 2020; 16:32-39. [PMID: 32595767 DOI: 10.17925/ee.2020.16.1.32] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/08/2019] [Indexed: 12/15/2022]
Abstract
Cancer immunotherapy and targeted therapy, though less toxic than conventional chemotherapy, can increase the risk of thyroid dysfunction. Immune checkpoint inhibitors render the cancer cells susceptible to immune destruction, but also predispose to autoimmune disorders like primary hypothyroidism as well as central hypothyroidism secondary to hypophysitis. Tyrosine kinase inhibitors act by blocking vascular endothelial growth factor receptors and their downstream targets. Disruption of the vascular supply from the inhibition of endothelial proliferation damages not only cancer cells but also organs with high vascularity like the thyroid. Interferon-α, interleukin-2 and thalidomide analogues can cause thyroid dysfunction by immune modulation. Alemtuzumab, a monoclonal antibody directed against the cell surface glycoprotein CD52 causes Graves' disease during immune reconstitution. Metaiodobenzylguanidine, combined with 131-iodine, administered as a radiotherapeutic agent for tumours derived from neural crest cells, can cause primary hypothyroidism. Bexarotene can produce transient central hypothyroidism by altering the feedback effect of thyroid hormone on the pituitary gland. Thyroid dysfunction can be managed in the usual manner without a requirement for dose reduction or discontinuation of the implicated agent. This review aims to highlight the effect of various anticancer agents on thyroid function. Early recognition and appropriate management of thyroid disorders during cancer therapy will help to improve treatment outcomes.
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Affiliation(s)
| | - Alpesh Goyal
- All Indian Institute of Medical Sciences, New Delhi, India
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24
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Anti-thyroid antibodies and thyroid echo pattern at baseline as risk factors for thyroid dysfunction induced by anti-programmed cell death-1 antibodies: a prospective study. Br J Cancer 2020; 122:771-777. [PMID: 32009131 PMCID: PMC7078193 DOI: 10.1038/s41416-020-0736-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 12/20/2019] [Accepted: 01/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background Anti-programmed cell death-1 (PD-1) antibodies can cause thyroid dysfunction. However, no predictive biomarkers enabling stratification of thyroid dysfunction risk have been identified. Methods A total of 209 patients treated with an anti-PD-1 antibody were evaluated for anti-thyroid antibodies at baseline and prospectively for thyroid function every 6 weeks for 24 weeks after treatment initiation, and then observed until the visits stopped. Thyroid ultrasonography was performed if the patient was positive for anti-thyroid antibodies at baseline. Results Of the 209 patients, 19 (9.1%) developed thyroid dysfunction (destructive thyroiditis or hypothyroidism). The cumulative incidence of thyroid dysfunction was significantly higher in patients who were positive vs. negative for anti-thyroid antibodies (15/44 [34.1%] vs. 4/165 [2.4%], p < 0.001). Forty-two patients positive for anti-thyroid antibodies at baseline were divided into two groups according to the presence of an irregular echo pattern. The cumulative incidence of thyroid dysfunction was significantly higher in those with an irregular vs. a regular echo pattern (13/23 [56.5%] vs. 1/19 [5.3%], p = 0.001). None of the patients developed thyroid dysfunction after the initial 24-week period. Conclusions The risk of thyroid dysfunction induced by anti-PD-1 antibodies can be predicted by evaluation of anti-thyroid antibodies and the thyroid echo pattern at baseline. Trial registration UMIN000019024.
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Agrawal L, Bacal A, Jain S, Singh V, Emanuele N, Emanuele M, Meah F. Immune checkpoint inhibitors and endocrine side effects, a narrative review. Postgrad Med 2020; 132:206-214. [PMID: 31876444 DOI: 10.1080/00325481.2019.1709344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Immune checkpoint inhibitors (ICPIs) are novel drugs in the field of oncology however carry the risk of immune-related dermatologic, gastrointestinal, and endocrine side effects which can be fatal. These new innovative immunoregulatory drugs have intertwined the fields of oncology and endocrinology. CTLA-4 and PD-1 are co-inhibitory receptors on T cells that turn the T cell 'off' when binding to receptors on APCs. Tumor cells can also carry receptors for CTLA- and PD-1. By rendering T cells inactive, tumor cells can evade immune attack. Antibodies that bind to CTLA-4 and PD-1 lead to T cell activation and destruction of both tumor and normal host cells. ICPIs have been used in a variety of malignancies including melanoma, kidney cancer, and non-small cell lung cancer. A unique underrecognized side effect of the autoimmune response is hypophysitis leading to central adrenal insufficiency which can be fatal. Additional immune-related adverse events (irAEs) include hypothyroidism, hyperthyroidism, diabetes, and hypoparathyroidism.
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Affiliation(s)
- L Agrawal
- Department of Endocrinology, Edward Hines Junior VA Hospital, Hines, IL, USA
| | - A Bacal
- Department of Endocrinology, Loyola University Medical Center, Maywood, IL, USA
| | - S Jain
- Department of Endocrinology, Loyola University Medical Center, Maywood, IL, USA
| | - V Singh
- Department of Endocrinology, Loyola University Medical Center, Maywood, IL, USA
| | - N Emanuele
- Department of Endocrinology, Edward Hines Junior VA Hospital, Hines, IL, USA
| | - Ma Emanuele
- Department of Endocrinology, Loyola University Medical Center, Maywood, IL, USA
| | - F Meah
- Department of Endocrinology, Edward Hines Junior VA Hospital, Hines, IL, USA
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Dougan M, Pietropaolo M. Time to dissect the autoimmune etiology of cancer antibody immunotherapy. J Clin Invest 2020; 130:51-61. [PMID: 31895048 PMCID: PMC6934191 DOI: 10.1172/jci131194] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Immunotherapy has transformed the treatment landscape for a wide range of human cancers. Immune checkpoint inhibitors (ICIs), monoclonal antibodies that block the immune-regulatory "checkpoint" receptors CTLA-4, PD-1, or its ligand PD-L1, can produce durable responses in some patients. However, coupled with their success, these treatments commonly evoke a wide range of immune-related adverse events (irAEs) that can affect any organ system and can be treatment-limiting and life-threatening, such as diabetic ketoacidosis, which appears to be more frequent than initially described. The majority of irAEs from checkpoint blockade involve either barrier tissues (e.g., gastrointestinal mucosa or skin) or endocrine organs, although any organ system can be affected. Often, irAEs resemble spontaneous autoimmune diseases, such as inflammatory bowel disease, autoimmune thyroid disease, type 1 diabetes mellitus (T1D), and autoimmune pancreatitis. Yet whether similar molecular or pathologic mechanisms underlie these apparent autoimmune adverse events and classical autoimmune diseases is presently unknown. Interestingly, evidence links HLA alleles associated with high risk for autoimmune disease with ICI-induced T1D and colitis. Understanding the genetic risks and immunologic mechanisms driving ICI-mediated inflammatory toxicities may not only identify therapeutic targets useful for managing irAEs, but may also provide new insights into the pathoetiology and treatment of autoimmune diseases.
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Affiliation(s)
- Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Massimo Pietropaolo
- Diabetes Research Center, Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Nogueira E, Newsom-Davis T, Morganstein DL. Immunotherapy-induced endocrinopathies: assessment, management and monitoring. Ther Adv Endocrinol Metab 2019; 10:2042018819896182. [PMID: 31903179 PMCID: PMC6933543 DOI: 10.1177/2042018819896182] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/29/2019] [Indexed: 12/13/2022] Open
Abstract
Immunotherapy with checkpoint inhibitors has transformed the treatment of cancer, but frequently results in immune-mediated adverse events affecting multiple organs, amongst which endocrine adverse events are frequent. The patterns of endocrine adverse events differ between inhibitors of the CTLA-4 and PD-1/PD-L1 pathways, but most frequently involve the thyroid and pituitary with insulin deficient diabetes also emerging as an important adverse event. These frequently result in long-lasting hormone deficiency requiring replacement. This review explores the mechanism of action of checkpoint inhibitors and details the expected endocrine adverse events and typical presentations. The effect of high-dose glucocorticoids therapy to treat nonendocrine adverse events is also discussed.
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Affiliation(s)
- Edson Nogueira
- Department of Endocrinology, Chelsea and
Westminster Hospital, London, UK
| | - Tom Newsom-Davis
- Department of Medical Oncology, Chelsea and
Westminster Hospital, London, UK
| | - Daniel L. Morganstein
- Department of Endocrinology, Chelsea and
Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
- Royal Marsden Hospital, London, UK
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28
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Extraocular Muscle Enlargement and Thyroid Eye Disease-like Orbital Inflammation Associated with Immune Checkpoint Inhibitor Therapy in Cancer Patients. Ophthalmic Plast Reconstr Surg 2019; 35:50-52. [PMID: 29927883 DOI: 10.1097/iop.0000000000001161] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE To describe thyroid eye disease (TED)-like orbital inflammatory syndrome in 3 cancer patients treated with immune checkpoint inhibitors. METHODS All consecutive patients treated by the senior author who were receiving immune checkpoint inhibitors and developed TED-like orbital inflammation were included. RESULTS Three cancer patients treated with immune checkpoint inhibitors developed orbital inflammation. The first patient was treated with a combination of a cytotoxic T-lymphocyte antigen-4 inhibitor and a programmed cell death protein 1 inhibitor and developed TED-like orbital inflammation with normal thyroid function and antibody levels. The second patient had a previous diagnosis of Graves disease without TED, and developed TED soon after initiating treatment with a programmed cell death protein 1 inhibitor. The third patient developed acute hyperthyroidism with symptomatic TED following treatment with an investigational cytotoxic T-lymphocyte antigen-4 inhibitor agent. All 3 patients were managed with either systemic steroids or observation, with resolution of their symptoms and without the need to halt immune checkpoint inhibitor treatment for their cancer. DISCUSSION AND CONCLUSIONS TED-like orbital inflammation may occur as a side effect of immune checkpoint inhibitor therapy with anti-cytotoxic T-lymphocyte antigen-4 or anti-PD-1 inhibitors. To the best of their knowledge, this is the first reported case of TED as a result of programmed cell death protein 1 inhibitor monotherapy. All 3 patients were treated with systemic steroids and responded quickly while continuing treatment with immune checkpoint inhibitors for their cancer. With increasing use of this class of drugs, clinicians should be familiar with the clinical manifestations and treatments for this adverse reaction.
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Mora N, Vu KN, Hoang TD, Mai VQ, Shakir MKM. R-CHOP-Associated Graves' Hyperthyroidism. Case Rep Oncol 2019; 12:581-588. [PMID: 31543772 PMCID: PMC6738228 DOI: 10.1159/000501714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 12/02/2022] Open
Abstract
Radiation-induced thyroid dysfunction following oncologic treatment is not uncommon, however limited literature data has been found on patients that underwent chemotherapy only. A change in thyrometabolic autoimmune status is also a rare entity. We present a case of newly diagnosed Graves' thyrotoxicosis following a successful R-CHOP (Rituximab, Cyclophosphamide, Doxorubicine, Vincristine and Prednisone) treatment in a patient with concurrent abdominal and thyroid diffuse large B-cell lymphoma (DLBCL). Following chemotherapy, PET CT showed resolution of FDG-avid thyroid nodule as well as no evidence of the thyroid mass on repeat ultrasound. Her thyroid function also normalized. During her follow-up visit, patient reported significant unintentional weight loss and persistent fatigue over the past couple months. Repeat laboratory evaluation revealed TSH 0.005 mIU/mL, FT4 6.73 ng/dL and thyroid stimulating immunoglobulin (TSI) 535 (ref <140%). She was started on methimazole followed by radioactive iodine therapy. This unique case of Graves' disease following R-CHOP treatment in patients with known Hashimoto's and thyroid lymphoma is one of the first to be reported in the literature. The swing of pendulum from Hashimoto's to Graves' disease is very uncommon. As clinicians, we need to continue monitoring for clinical and biochemical thyroid dysfunction in this subset of population.
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Affiliation(s)
- Natalie Mora
- Department of Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Katherine N Vu
- Department of Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Thanh D Hoang
- Department of Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Vinh Q Mai
- Department of Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Mohamed K M Shakir
- Department of Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Touhami S, Audo I, Terrada C, Gaudric A, LeHoang P, Touitou V, Bodaghi B. Neoplasia and intraocular inflammation: From masquerade syndromes to immunotherapy-induced uveitis. Prog Retin Eye Res 2019; 72:100761. [DOI: 10.1016/j.preteyeres.2019.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/16/2019] [Accepted: 05/01/2019] [Indexed: 12/18/2022]
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Hoefsmit EP, Rozeman EA, Haanen JBAG, Blank CU. Susceptible loci associated with autoimmune disease as potential biomarkers for checkpoint inhibitor-induced immune-related adverse events. ESMO Open 2019; 4:e000472. [PMID: 31423333 PMCID: PMC6677983 DOI: 10.1136/esmoopen-2018-000472] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/01/2019] [Accepted: 03/19/2019] [Indexed: 12/13/2022] Open
Abstract
Unprecedented successes regarding cancer immunotherapy have been achieved, in which therapeutic agents are used to target immune cells rather than cancer cells. The most effective immunotherapy to date is the group of immune checkpoint inhibitors (CPI), targeting, for example, cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) or programmed cell death protein (PD-1). TThe combination of these therapies (anti-PD-1 with anti-CTLA-4) induces high response rates, and seem to be increased further when applied in early-stage disease. However, combined CTLA-4 plus PD-1 blockade causes frequent high-grade immune-related adverse events (irAE). To date, research on biological mechanism of irAEs is scarce and no widely accepted biomarkers predicting onset of severe irAEs have been identified. The similarity of irAEs to autoimmune disorders fuels the hypothesis that irAEs may be linked to susceptible genetic loci related to various autoimmune diseases. In this review, we extensively searched for susceptible loci associated with various autoimmune diseases, and pooled them in groups most likely to be associated with CPI-induced irAEs. These sets could be used in future research on predicting irAEs and guide physicians in a more refined and personal manner.
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Affiliation(s)
- Esmée P Hoefsmit
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Elisa A Rozeman
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Medical Oncology Department, Netherlands Cancer Institute-Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
| | - John B A G Haanen
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Medical Oncology Department, Netherlands Cancer Institute-Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
| | - Christian U Blank
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Medical Oncology Department, Netherlands Cancer Institute-Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
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Brancatella A, Viola N, Brogioni S, Montanelli L, Sardella C, Vitti P, Marcocci C, Lupi I, Latrofa F. Graves' Disease Induced by Immune Checkpoint Inhibitors: A Case Report and Review of the Literature. Eur Thyroid J 2019; 8:192-195. [PMID: 31602361 PMCID: PMC6738242 DOI: 10.1159/000501824] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/29/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION In the last few years, immune checkpoint inhibitors (ICPis) have become a common treatment of cancer. ICPis are associated with peculiar immune side effects, termed immune-related adverse events (irAEs). Thyroid disfunction is a common irAE, but clinical manifestation, severity, and pathogenesis can be variable. While destructive thyroiditis and hypothyroidism are the most common thyroid irAEs induced by ICPis, autoimmune hyperthyroidism (Graves' disease) is rare. We describe a case of a Graves' disease induced by anti-PD-1 therapy and we review the previous reports on this issue. CASE PRESENTATION A 51-year-old man developed an overt autoimmune hyperthyroidism 2 months after he had started nivolumab (anti-PD-1) therapy for a metastatic non-small cell lung cancer. Although TSH-receptor autoantibodies (TRAb) were negative, the persistence of hyperthyroidism, the hypervascular pattern at thyroid ultrasound, and the high uptake at thyroid scintigraphy were all features suggestive of Graves' disease. Methimazole was started with the prompt restoration of euthyroidism. TRAb remained undetectable during the entire follow-up. CONCLUSIONS Autoimmune hyperthyroidism can be induced by anti-PD-1 treatment. TRAb were negative in both cases of nivolumab-induced Graves' disease described to date. A correct differential diagnosis between destructive thyroiditis and autoimmune hyperthyroidism is crucial for the appropriate treatment.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Francesco Latrofa
- *Francesco Latrofa, MD, Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, Via Paradisa 2, IT–56124 Pisa (Italy), E-Mail
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Jannin A, Penel N, Ladsous M, Vantyghem MC, Do Cao C. Tyrosine kinase inhibitors and immune checkpoint inhibitors-induced thyroid disorders. Crit Rev Oncol Hematol 2019; 141:23-35. [PMID: 31202955 DOI: 10.1016/j.critrevonc.2019.05.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/21/2019] [Accepted: 05/27/2019] [Indexed: 12/11/2022] Open
Abstract
Recently, tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICPIs) have emerged as new classes of anticancer therapies. Although generally considered less toxic than cytotoxic chemotherapy, these new drugs can cause significant unanticipated side effects including thyroid dysfunction. This review provides a literature assessment of thyroid dysfunctions induced by TKI and ICPIs. We intend to define for these two classes the frequency of thyroid involvement, the potential mechanisms that result in this toxicity, the clinical-biological impact and the therapeutic management. Detection of thyroid dysfunction requires monitoring of TSH, in combination with free T4 if needed and, depending on the clinical impact and the kinetics of biological abnormalities, starting symptomatic treatment of hyperthyroidism and/or correcting hypothyroidism.
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Affiliation(s)
- Arnaud Jannin
- Department of Endocrinology and Metabolism, CHU Lille, 59037 Lille, France.
| | - Nicolas Penel
- Medical Oncology Department, Oscar Lambret Cancer Centre, Lille, France; Medical Oncology Department, CHU Lille, 59037, Lille France.
| | - Miriam Ladsous
- Department of Endocrinology and Metabolism, CHU Lille, 59037 Lille, France.
| | - Marie Christine Vantyghem
- Department of Endocrinology and Metabolism, CHU Lille, 59037 Lille, France; UMR 1190 Translational Research in Diabetes INSERM, 59000 Lille, France.
| | - Christine Do Cao
- Department of Endocrinology and Metabolism, CHU Lille, 59037 Lille, France.
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Tan MH, Iyengar R, Mizokami-Stout K, Yentz S, MacEachern MP, Shen LY, Redman B, Gianchandani R. Spectrum of immune checkpoint inhibitors-induced endocrinopathies in cancer patients: a scoping review of case reports. Clin Diabetes Endocrinol 2019; 5:1. [PMID: 30693099 PMCID: PMC6343255 DOI: 10.1186/s40842-018-0073-4] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Since 2011 six immune checkpoint inhibitors (ICI) have been approved to treat patients with many advanced solid tumor and hematological malignancies to improve their prognosis. Case reports of their endocrine immune-related adverse events [irAEs]) are increasingly published as more real-world patients with these malignancies are treated with these drugs. They alert physicians of a drug's AEs (which may change during a drug's life cycle) and contribute to post-marketing safety surveillance. Using a modified framework of Arksey and O'Malley, we conducted a scoping review of the spectrum and characteristics of ICI-induced endocrinopathies case reports before and after ICIs are marketed. METHODS In July 2017, we searched, without date and language restrictions, 4 citation databases for ICI-induced endocrinopathies. We also hand-searched articles' references, contents of relevant journals, and ran supplemental searches to capture recent reports through January 2018. For this study, a case should have information on type of cancer, type of ICI, clinical presentation, biochemical tests, treatment plus temporal association of ICI initiation with endocrinopathies. Two endocrinologists independently extracted the data which were then summarized and categorized. RESULTS One hundred seventy nine articles reported 451 cases of ICI-induced endocrinopathies - 222 hypopituitarism, 152 thyroid disorders, 66 diabetes mellitus, 6 primary adrenal insufficiencies, 1 ACTH-dependent Cushing's syndrome, 1 hypoparathyroidism and 3 diabetes insipidus cases. Their clinical presentations reflect hormone excess or deficiency. Some were asymptomatic and others life-threatening. One or more endocrine glands could be affected. Polyglandular endocrinopathies could present simultaneously or in sequence. Many occur within 5 months of therapy initiation; a few occurred after ICI was stopped. Mostly irreversible, they required long-term hormone replacement. High dose steroids were used when non-endocrine AEs coexisted or as therapy in adrenal insufficiency. There was variability of information in the case reports but all met the study criteria to make a diagnosis. CONCLUSIONS The spectrum of ICI-induced endocrinopathies is wide (5 glands affected) and their presentation varied (12 endocrinopathies). Clinical reasoning integrating clinical, biochemical and treatment information is needed to properly diagnose and manage them. Physicians should be vigilant for their occurrence and be able to diagnose, investigate and manage them appropriately at onset and follow-up.
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Affiliation(s)
- Meng H. Tan
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Ravi Iyengar
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
- Present address: Endocrinology, Rush University Medical Center, 1725 West Harrison Street, Chicago, IL 60612 USA
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Sarah Yentz
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Mark P. MacEachern
- Taubman Health Sciences Library, University of Michigan, 1135 Catherine Street, Ann Arbor, MI 48109 USA
| | - Li Yan Shen
- Affiliated Hospital of QingDao University, QingDao, 16 Jiangsu Road, Sinan Qu, Qingdao, Shi, Shandong Sheng China
| | - Bruce Redman
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Roma Gianchandani
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
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Ramos-Levi AM, Rogado J, Sanchez-Torres JM, Colomer R, Marazuela M. Nivolumab-induced thyroid dysfunction in patients with lung cancer. ENDOCRINOLOGÍA, DIABETES Y NUTRICIÓN (ENGLISH ED.) 2019. [DOI: 10.1016/j.endien.2018.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Ferrari SM, Fallahi P, Galetta F, Citi E, Benvenga S, Antonelli A. Thyroid disorders induced by checkpoint inhibitors. Rev Endocr Metab Disord 2018; 19:325-333. [PMID: 30242549 DOI: 10.1007/s11154-018-9463-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Immune checkpoint inhibitors are drugs that inhibit the "checkpoint molecules". Different types of cancer immune checkpoint inhibitors have been approved recently: CTLA-4 monoclonal antibodies (as ipilimumab); anti-PD-1 monoclonal antibodies (as pembrolizumab and nivolumab); and anti-PD-L1 monoclonal antibodies (as atezolizumab, avelumab, and durmalumab). The increased immune response induced by these agents leads to immune-related adverse events (irAEs), that can vary from mild to fatal, according to the organ system and severity. Immune-related endocrine toxicities are thyroid dysfunctions, hypophysitis, adrenal insufficiency, and type 1 diabetes mellitus, and are usually irreversible in 50%. In particular, hypophysitis is the most frequent anti-CTLA-4-antibodies-related irAE, while thyroid abnormalities (as hypothyroidism, thyrotoxicosis, painless thyroiditis, or even "thyroid storm") are more frequently associated with anti-PD-1-antibodies. The combination of anti-CTLA-4-antibodies, with anti-PD-1-antibodies, is associated with about 30% of irAEs. Clinical signs and symptoms vary according to the influenced target organ. Endocrinopathies can often be managed by the treating oncologist. However in more severe cases (i.e. in the presence of insulin-dependent diabetes, adrenal insufficiency, or disorders of gonadal hormones, or severe hyperthyroidism, or hypothyroidism, or long-lasting management of hypophysitis) an endocrinological evaluation, and a prompt therapy, are needed.
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Affiliation(s)
- Silvia Martina Ferrari
- Department of Clinical and Experimental Medicine, University of Pisa, School of Medicine, Via Savi, 10, I-56126, Pisa, Italy
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Fabio Galetta
- Department of Clinical and Experimental Medicine, University of Pisa, School of Medicine, Via Savi, 10, I-56126, Pisa, Italy
| | - Emanuele Citi
- Department of Clinical and Experimental Medicine, University of Pisa, School of Medicine, Via Savi, 10, I-56126, Pisa, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women's Endocrine Health, Azienda Ospedaliera Universitaria Policlinico 'G. Martino', I-98125, Messina, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, School of Medicine, Via Savi, 10, I-56126, Pisa, Italy.
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Abstract
PURPOSE OF REVIEW The pathophysiology of thyroid eye disease (TED) is still not fully understood. However, recently described risk factors and molecular findings have brought new insights into the mechanisms of TED and could lead to the emerging use of more targeted therapies. This article aims to review the clinical findings of TED, and the most recent advances in our understanding of the risk factors and therapeutic options for TED. RECENT FINDINGS Smoking has been recently shown to have an impact on specific gene expression involved in several disease-related pathways, which seems to be reversible with smoking cessation. This finding further emphasizes the importance of smoking cessation in the prevention and treatment of TED. Selenium deficiency and high-serum cholesterol have been described to be potential independent risk factors for TED and their management could decrease the incidence and severity of TED. In terms of therapeutic options, immunomodulatory medications have shown some promising results for disease control in TED over the past years, but further randomized prospective studies with larger sample sizes are still needed to prove their efficacy. A new technique of P brachytherapy was shown to have quick therapeutic effects on TED without significant side effects and could be a promising therapy for selected cases of TED. SUMMARY TED is one of the most common autoimmune inflammatory disorders of the orbit. Although its pathophysiology remains unclear, newly described genetic findings and risk factors could help in explaining its occurrence and guide future therapies. Immunosuppressant medications are increasingly used in the management of TED, but further studies are needed to confirm their effectiveness.
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Iyer PC, Cabanillas ME, Waguespack SG, Hu MI, Thosani S, Lavis VR, Busaidy NL, Subudhi SK, Diab A, Dadu R. Immune-Related Thyroiditis with Immune Checkpoint Inhibitors. Thyroid 2018; 28:1243-1251. [PMID: 30132401 PMCID: PMC6157359 DOI: 10.1089/thy.2018.0116] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although immune-related thyroiditis (irT) with immune checkpoint inhibitors (ICI) is a common consequence, its natural course and management recommendations are not well characterized in existing guidelines. This study sought to investigate the evolution of irT and describe its course and sequelae. METHODS This was a retrospective study of cancer patients treated with ICI between November 2014 and July 2016 at MD Anderson Cancer Center and referred for endocrinology evaluation for suspected irT. Patients included had normal baseline thyroid function tests prior to starting ICI and developed thyrotoxicosis due to irT. RESULTS Of 657 patients treated with ICI during the study period, 43(6.5%) met the inclusion criteria. ICI included: ipilimumab + nivolumab (40%), nivolumab (33%), pembrolizumab (21%), and other (7%). Cancer diagnoses observed were melanoma (23%), renal-cell carcinoma (21%), lung cancer (19%), bladder cancer (12%), colon cancer (9%), and other cancers (15%). Median time from ICI start to thyrotoxicosis was 5.3 weeks (range 0.6-19.6 weeks). Clinically, patients presented with painless thyroiditis, and 67% were asymptomatic during the thyrotoxicosis phase. Thyrotoxicosis lasted a median of six weeks (range 2.6-39.7 weeks). Hypothyroidism developed in 37 (84%) patients at a median of 10.4 weeks (range 3.4-48.7 weeks) after starting ICI. These patients remained on levothyroxine and ICI at a median follow-up of 57.4 weeks (range 1-156.7 weeks) from hypothyroidism onset. Four patients recovered without initiating levothyroxine and remained euthyroid at a median follow-up of 11.35 months (range 4.43-14.43 months). Subgroup analysis of ipilimumab + nivolumab versus nivolumab alone showed a median time to thyrotoxicosis of two weeks [confidence interval (CI) 3.5-8.4] versus six weeks ([CI 1.2-2.8]; p = 0.26) and time to hypothyroidism of 10 weeks [CI 8.1-11.9] versus 17 weeks ([CI 8.8-25.2]; p = 0.029) after starting ICI. Thyroid peroxidase and thyroglobulin antibodies were present in 45% and 33% at the time of irT diagnosis. CONCLUSIONS IrT manifests as an early onset of thyrotoxicosis, which is largely asymptomatic, followed by rapid transition to hypothyroidism requiring long-term levothyroxine substitution. The evolution of irT is more rapid with combination ICI. Frequent monitoring of thyroid function tests during ICI is warranted. Future guidelines need to recognize this entity and incorporate their management.
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Affiliation(s)
- Priyanka C. Iyer
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, Texas
| | - Maria E. Cabanillas
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven G. Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mimi I. Hu
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sonali Thosani
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victor R. Lavis
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naifa L. Busaidy
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sumit K. Subudhi
- Department of Genitourinary Medical Oncology; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adi Diab
- Melanoma Medical Oncology, Division of Cancer Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ramona Dadu
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine; The University of Texas MD Anderson Cancer Center, Houston, Texas
- Address correspondence to:Ramona Dadu, MDDepartment of Endocrine Neoplasia and Hormonal DisordersThe University of Texas MD Anderson Cancer Center1400 Pressler Street, Unit 1461Houston, TX 77230-1402
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Alnabulsi R, Hussain A, DeAngelis D. Complete ophthalmoplegia in Ipilmumab and Nivolumab combination treatment for metastatic melanoma. Orbit 2018; 37:381-384. [PMID: 29381409 DOI: 10.1080/01676830.2017.1423349] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 12/29/2017] [Indexed: 06/07/2023]
Abstract
Ipilimumab and Nivolumab are novel monoclonal antibodies that have recently been used successfully for treatment of metastatic melanoma. Ipilimumab is a human monoclonal antibody against Cytotoxic T Lymphocyte Antigen 4 (CTLA4) receptor, which suppresses T-cell proliferation and stimulates an inflammatory response against cancer cells. Nivolumab is an IgG4 monoclonal antibody against the cytotoxic T lymphocyte associated programmed death 1 receptor (PD-1). Ipilimumab and Nivolumab combination treatment has been shown to induce remission and prolong survival in patients with metastatic melanoma. The side effect profile of these medications has not been well studied. One entity of the side effects reported in the literature is immune-related adverse events (irAEs). There have been few case reports where these events were serious and irreversible. In this case report, we describe a fatal and severe diffuse panmyositis that involved the cardiac, respiratory, and extraocular muscles in a patient with metastatic melanoma secondary to combination treatment with Ipilimumab/Nivolumab.
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Affiliation(s)
- Reem Alnabulsi
- a Department of Ophthalmology and Vision Sciences , University of Toronto , Toronto , Ontario , Canada
| | - Ahsen Hussain
- a Department of Ophthalmology and Vision Sciences , University of Toronto , Toronto , Ontario , Canada
| | - Dan DeAngelis
- a Department of Ophthalmology and Vision Sciences , University of Toronto , Toronto , Ontario , Canada
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Nardin C, Borot S, Beaudoin MA, Cattin F, Puzenat E, Gauthier AS, Schillo F, Borg C, Aubin F. Long-term adverse event: inflammatory orbitopathy induced by pembrolizumab in a patient with metastatic melanoma. Invest New Drugs 2018; 37:375-377. [PMID: 30145624 DOI: 10.1007/s10637-018-0659-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/20/2018] [Indexed: 11/26/2022]
Abstract
The recent advent of immune checkpoint inhibitors (ICI), including anti-programmed cell death 1 protein (anti-PD-1) agents has revolutionized the therapeutic approach of metastatic malignancies. Yet, ICI can disrupt immune tolerance resulting in enhanced immune activation in normal tissues with significant toxicity. A dysregulated activation of T-cells directed to normal tissues stands as the main mechanism of immune-related adverse events (irAE). To date, only two cases of immune-related inflammatory orbitopathy related to anti-PD-1 agents have been reported. This rare immune adverse event usually occurred early after ICI initiation. Here, we report the first case of late inflammatory orbitopathy occurring in a melanoma patient treated with pembrolizumab. Consequently, the occurrence of irAE under ICI should be monitored, even late after treatment instauration.
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Affiliation(s)
- Charlée Nardin
- Service de Dermatologie, Centre Hospitalier Universitaire, 3 Boulevard Alexandre Fleming, 25030, Besançon cedex, France.
- EA 3181 Université de Franche Comté, Besançon cedex, France.
| | - Sophie Borot
- Service d'Endocrinologie, Centre Hospitalier Universitaire, Besançon, France
| | | | - Françoise Cattin
- Service de Radiologie, Centre Hospitalier Universitaire, Besançon, France
| | - Eve Puzenat
- Service de Dermatologie, Centre Hospitalier Universitaire, 3 Boulevard Alexandre Fleming, 25030, Besançon cedex, France
- EA 3181 Université de Franche Comté, Besançon cedex, France
| | | | - Franck Schillo
- Service d'Endocrinologie, Centre Hospitalier Universitaire, Besançon, France
| | - Christophe Borg
- Service d'Oncologie, Centre Hospitalier Universitaire, Besançon, France
| | - François Aubin
- Service de Dermatologie, Centre Hospitalier Universitaire, 3 Boulevard Alexandre Fleming, 25030, Besançon cedex, France
- EA 3181 Université de Franche Comté, Besançon cedex, France
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Park ESY, Rabinowits G, Hamnvik OPR, Dagi LR. A case of Graves' ophthalmopathy associated with pembrolizumab (Keytruda) therapy. J AAPOS 2018; 22:310-312. [PMID: 29626663 DOI: 10.1016/j.jaapos.2018.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 10/17/2022]
Abstract
We present the first reported case of Graves' orbitopathy induced by pembrolizumab, a new FDA-approved drug used for the treatment of multiple refractory solid tumors and classic Hodgkin lymphoma. Pembrolizumab elicits T-lymphocyte proliferation; we suspect that thyroid eye disease may result in some cases.
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Affiliation(s)
- Ella S Y Park
- Yonsei University College of Medicine, Seoul, South Korea
| | - Guilherme Rabinowits
- Medical Oncology Department, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ole-Petter R Hamnvik
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Linda R Dagi
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Girotra M, Hansen A, Farooki A, Byun DJ, Min L, Creelan BC, Callahan MK, Atkins MB, Sharon E, Antonia SJ, West P, Gravell AE. The Current Understanding of the Endocrine Effects From Immune Checkpoint Inhibitors and Recommendations for Management. JNCI Cancer Spectr 2018; 2:pky021. [PMID: 30057972 PMCID: PMC6054022 DOI: 10.1093/jncics/pky021] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/03/2018] [Accepted: 04/20/2018] [Indexed: 12/17/2022] Open
Abstract
Clinical trials in the past decade have established the antitumor effects of immune checkpoint inhibition as a revolutionary treatment for cancer. Namely, blocking antibodies to cytotoxic T-lymphocyte antigen 4 and programmed death 1 or its ligand have reached routine clinical use. Manipulation of the immune system is not without side effects, and autoimmune toxicities often known as immune-related adverse events (IRAEs) are observed. Endocrine IRAEs, such as hypophysitis, thyroid dysfunction, and insulin-dependent diabetes mellitus, can present with unique profiles that are not seen with the use of traditional chemotherapeutics. In this Review, we discuss the current hypotheses regarding the mechanism of these endocrinopathies and their clinical presentations. Further, we suggest guidelines and algorithms for patient management and future clinical trials to optimize the detection and treatment of immune checkpoint–related endocrinopathies.
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Affiliation(s)
- Monica Girotra
- Endocrine Division, Department of Medicine, Weill Cornell Medical College
- Correspondence to: Monica Girotra, MD, Endocrine Services, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065 (e-mail: )
| | - Aaron Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Azeez Farooki
- Endocrine Division, Department of Medicine, Weill Cornell Medical College
| | | | - Le Min
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA
| | | | | | | | - Elad Sharon
- Cancer Therapy Evaluation Program, National Cancer Institute, Rockville, MD
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Abstract
PURPOSE To review immune checkpoint inhibitor indications and ophthalmic side effects. METHODS A literature review was performed using a PubMed search for publications between 1990 and 2017. RESULTS Immune checkpoint inhibitors are designed to treat system malignancies by targeting one of three ligands, leading to T-cell activation for attack against malignant cells. These ligands (and targeted drug) include cytotoxic T-lymphocyte antigen-4 (CTLA-4, ipilimumab), programmed death protein 1 (PD-1, pembrolizumab, nivolumab), and programmed death ligand-1 (PD-L1, atezolizumab, avelumab, durvalumab). These medications upregulate the immune system and cause autoimmune-like side effects. Ophthalmic side effects most frequently manifest as uveitis (1%) and dry eye (1-24%). Other side effects include myasthenia gravis (n = 19 reports), inflammatory orbitopathy (n = 11), keratitis (n = 3), cranial nerve palsy (n = 3), optic neuropathy (n = 2), serous retinal detachment (n = 2), extraocular muscle myopathy (n = 1), atypical chorioretinal lesions (n = 1), immune retinopathy (n = 1), and neuroretinitis (n = 1). Most inflammatory side effects are managed with topical or periocular corticosteroids, but advanced cases require systemic corticosteroids and cessation of checkpoint inhibitor therapy. CONCLUSION Checkpoint inhibitors enhance the immune system by releasing inhibition on T cells, with risk of autoimmune-like side effects. Ophthalmologists should include immune-related adverse events in their differential when examining cancer patients with new ocular symptoms.
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Ramos-Levi AM, Rogado J, Sanchez-Torres JM, Colomer R, Marazuela M. Nivolumab-induced thyroid dysfunction in patients with lung cancer. ACTA ACUST UNITED AC 2018; 66:26-34. [PMID: 29910159 DOI: 10.1016/j.endinu.2018.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/20/2018] [Accepted: 05/03/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Nivolumab is an anti-cancer monoclonal antibody that inhibits PD1 and modulates T-cell response. It has been shown to significantly improve survival in several types of cancer, but clinical trials have also reported an increased risk of developing immune-related adverse events (IRAEs). Endocrine IRAEs may be particularly relevant. OBJECTIVE To comprehensively evaluate the clinical presentation of endocrine IRAEs in patients with lung cancer treated with nivolumab. Potential risk factors are analyzed, and strategies for IRAE management are proposed. METHODS Forty consecutive patients treated with nivolumab for advanced non-small cell lung cancer (NSCLC) were studied, paying particular attention to development of endocrine IRAEs (thyroid, hypophyseal, adrenal, or pancreatic) and clinical outcome. RESULTS Thyroid function changes were found in 9 patients (22.5%), of which six developed hypothyroidism and three had hyperthyroidism after a median of 3.8 and 2.3 cycles of nivolumab respectively. Only one patient had thyroid-related symptoms. Thyroid autoimmunity was negative in all cases. Hyperthyroid patients showed no uptake in iodine scintigraphy, and their hormone values returned to normal in less than six months. Nivolumab was discontinued for toxicity in one patient. One patient with hyperthyroidism also developed autoimmune diabetes, and one patient with hypothyroidism also had hypogonadism. After a median follow-up of 7.6 months, 25 patients (62.5%) showed response to nivolumab. Univariate and multivariate analyses showed no differences between patients who developed thyroid changes and those who did not. CONCLUSIONS Thyroid changes after treatment with nivolumab are common and warrant active laboratory monitoring. The underlying mechanisms and their relevance deserve further research.
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Affiliation(s)
- Ana M Ramos-Levi
- Department of Endocrinology, Hospital Universitario de la Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, C/ Diego de León 62, 28006 Madrid, Spain.
| | - Jacobo Rogado
- Department of Medical Oncology, Hospital Universitario de la Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, C/ Diego de León 62, 28006 Madrid, Spain
| | - Jose Miguel Sanchez-Torres
- Department of Medical Oncology, Hospital Universitario de la Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, C/ Diego de León 62, 28006 Madrid, Spain
| | - Ramón Colomer
- Department of Medical Oncology, Hospital Universitario de la Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, C/ Diego de León 62, 28006 Madrid, Spain
| | - Mónica Marazuela
- Department of Endocrinology, Hospital Universitario de la Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, C/ Diego de León 62, 28006 Madrid, Spain
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Kähler KC, Hassel JC, Heinzerling L, Loquai C, Mössner R, Ugurel S, Zimmer L, Gutzmer R. Management of side effects of immune checkpoint blockade by anti-CTLA-4 and anti-PD-1 antibodies in metastatic melanoma. J Dtsch Dermatol Ges 2018; 14:662-81. [PMID: 27373241 DOI: 10.1111/ddg.13047] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CTLA-4 and PD-1 are potential targets for tumor-induced downregulation of lymphocytic immune responses. Immune checkpoint-modifying monoclonal antibodies oppose these effects, inducing T cell-mediated immune responses to various tumors including melanoma. Both anti-CTLA-4 and anti-PD-1 antibodies modify the interaction between tumor, antigen-presenting cells, and T lymphocytes. With respect to overall survival, clinical studies have shown a major benefit for the anti-CTLA-4 antibody ipilimumab as well as the two anti-PD-1 antibodies nivolumab and pembrolizumab. Following approval of ipilimumab in 2011, the latter two achieved market authorization in the summer of 2015. Immune responses thus induced and enhanced inevitably entail autoimmune phenomena, affecting various organs to varying degrees. Knowledge of these side effects is crucial with regard to prevention and management by treating physicians. Typically occurring early on and presenting with pronounced and persistent diarrhea, colitis represents a major and severe side effect. Other immune-mediated disorders include dermatitis, hypophysitis, thyroiditis, hepatitis, iridocyclitis as well as other less common autoimmune phenomena. Early recognition and initiation of treatment can reduce risks and sequelae for patients. This review describes the mechanisms of action of immune checkpoint blockade as well as its clinical effects in metastatic melanoma, with a detailed focus on the spectrum of adverse events and their therapeutic management.
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Affiliation(s)
- Katharina C Kähler
- Department of Dermatology, Venereology, and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jessica C Hassel
- Department of Dermatology, and National Cancer Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Lucie Heinzerling
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Carmen Loquai
- Department of Dermatology, Medical Faculty, University of Mainz, Mainz, Germany
| | - Rotraut Mössner
- Department of Dermatology, Venereology, and Allergology, University Medicine Göttingen, Göttingen, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany
| | - Ralf Gutzmer
- Hanover Skin Cancer Center, Department of Dermatology, Venereology, and Allergology, Hanover Medical College, Hanover, Germany
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Campredon P, Imbert P, Mouly C, Grunenwald S, Mazières J, Caron P. Severe Inflammatory Ophthalmopathy in a Euthyroid Patient during Nivolumab Treatment. Eur Thyroid J 2018; 7:84-87. [PMID: 29594059 PMCID: PMC5869363 DOI: 10.1159/000485742] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/23/2017] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Nivolumab is a promising treatment in patients with advanced malignancies. Among immune-related adverse events, autoimmune thyroid disorders are frequently reported. PATIENT A 61-year-old male patient had no history of familial or personal thyroid disease. In 2012, this patient, a heavy smoker, presented with non-small-cell lung cancer that was treated with radiotherapy and chemotherapy. In 2015, the cancer progressed with cervical compressive symptoms, and the patient was treated with nivolumab. RESULTS After 3 infusions, bilateral eyelid ptosis and bilateral conjunctival redness with chemosis were observed. Ophthalmologic examination revealed severe proptosis with complete ophthalmoplegia but with normal vision, color test, and optic disk. Thyroid function tests were normal (TSH = 0.65 mU/L, free T4 = 15.4 pmol/L) without anti-thyroperoxidase or anti-TSH receptor antibodies. CT scan of the orbits confirmed marked bilateral proptosis with expansion of the orbital adipose tissue without significant thickening of extraocular muscles. T2-weighted MRI showed inflammation of orbital adipose tissue. Nivolumab treatment was withdrawn, and the patient received weekly intravenous high-dose methylprednisolone (1 g for 2 weeks, 500 mg for 4 weeks, and 250 mg for 5 weeks). After the first 3 cycles, significant improvement of left chemosis was observed whereas bilateral ptosis and ophthalmoplegia were unchanged. The patient was euthyroid without thyroid autoimmunity 1 week prior to his death due to massive hemoptysis. CONCLUSION We report severe inflammatory ophthalmopathy in a euthyroid patient with non-small-cell lung cancer during nivolumab therapy. The occurrence of such ophthalmic adverse events is likely to increase during nivolumab therapy in patients with advanced malignancies.
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Affiliation(s)
- Pauline Campredon
- Department of Endocrinology and Metabolic Diseases, Larrey University Hospital, Toulouse, France
| | - Philippe Imbert
- Ophthalmologist, Clinique du Parc, Toulouse, France
- Multidisciplinary Thyroid Eye Consultation, Department of Endocrinology, Larrey University Hospital, Toulouse, France
| | - Céline Mouly
- Department of Endocrinology and Metabolic Diseases, Larrey University Hospital, Toulouse, France
| | - Solange Grunenwald
- Department of Endocrinology and Metabolic Diseases, Larrey University Hospital, Toulouse, France
| | - Julien Mazières
- Department of Pneumology, Larrey University Hospital, Toulouse, France
| | - Philippe Caron
- Department of Endocrinology and Metabolic Diseases, Larrey University Hospital, Toulouse, France
- *Philippe Caron, MD, Department of Endocrinology and Metabolic Diseases, Cardiovascular and Metabolic Unit, CHU Larrey, 24 Chemin de Pouvourville, TSA 30030, FR–31059 Toulouse Cedex (France), E-Mail
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Iglesias P. Cancer immunotherapy-induced endocrinopathies: Clinical behavior and therapeutic approach. Eur J Intern Med 2018; 47:6-13. [PMID: 28826822 DOI: 10.1016/j.ejim.2017.08.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/11/2017] [Accepted: 08/16/2017] [Indexed: 12/29/2022]
Abstract
Cancer immunotherapy has proven to be effective in a wide variety of tumors. The use of immune checkpoint blocking monoclonal antibodies has become a standard treatment regimen in some of them as advanced melanoma. However, given the mechanism of action, its use may be associated with immune-related adverse events that may complicate the clinical course and prognosis of patients. Among these are autoimmune endocrine adverse effects, such as hypophysitis, hypo and hyperthyroidism, and adrenal insufficiency. This review focuses on the most relevant and new aspects related to the incidence, clinical presentation, diagnosis and treatment of these adverse effects associated with different types of immune checkpoint inhibitors in cancer immunotherapy.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. de Colmenar, Km 9.100, 28034 Madrid, Spain.
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Antonelli A, Ferrari SM, Fallahi P. Current and future immunotherapies for thyroid cancer. Expert Rev Anticancer Ther 2017; 18:149-159. [PMID: 29241377 DOI: 10.1080/14737140.2018.1417845] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cancer immunotherapies were approved in recent years, including immune checkpoint inhibitors. Experience with ipilimumab (CTLA-4 antagonist), nivolumab and pembrolizumab (PD-1 antagonists), and atezolizumab (PD-L1 antagonist) has shown that the impact on overall survival in cancer patients is paramount. Immune checkpoint inhibitors target the immune system and they can be applied across multiple cancers; the response rate is ranging from 20 to 40%. Many studies have shown that thyroid cancer (TC) cells produce cytokines and chemokines, inducing several tumor-promoting effects. Targeting and/or lowering cytokines and chemokines concentrations within the tumor microenvironment would produce a therapeutic benefit. In TC, increased Treg and PD-1+ T cell frequencies are indicative of aggressive disease and PD-L1 expression correlates with a greater risk of recurrence. Area covered: After performing a literature search, a few pioneering studies have evaluated immunotherapy in thyroid cancer. More recently a case has been described involving anaplastic thyroid cancer treated with vemurafenib and nivolumab, with substantial regression and complete radiographic and clinical remission. Expert commentary: The use of immune checkpoint inhibitors in aggressive TC has not yet been extensively investigated and further studies in a large number of TC patients are urgently needed.
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Affiliation(s)
- Alessandro Antonelli
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | | | - Poupak Fallahi
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
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Davis ME, Francis JH. Cancer Therapy with Checkpoint Inhibitors: Establishing a Role for Ophthalmology. Semin Oncol Nurs 2017; 33:415-424. [DOI: 10.1016/j.soncn.2017.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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