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Kundumadam S, Mohamad B, Muthusamy A, Kathi PR, Ehrinpreis MN. Pembrolizumab-Induced Immune-Mediated Hepatitis and Concurrent Hepatitis B Reactivation in a Patient With Non-Small Cell Lung Cancer. Cureus 2020; 12:e11522. [PMID: 33354466 PMCID: PMC7746005 DOI: 10.7759/cureus.11522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
New immuno-therapeutic agents like pembrolizumab used in cancer treatment are known to cause immune-mediated hepatitis. Most of these cases are straightforward when the onset of transaminitis correlates with the introduction of the medication. This agent causing hepatitis B reactivation has been reported only once. To have both these adverse effects occurring at the same time in a patient is uncommon and presents a clinical challenge. Our patient was a 49-year-old gentleman diagnosed with metastatic adenocarcinoma of the lung seven months ago. He was started on pembrolizumab, as the malignant tissue obtained during biopsy had high program death-ligand 1 (PDL1) expression. On reviewing the labs ordered during the time of cancer diagnosis, this man has evidence of chronic hepatitis B with positive hepatitis B surface antigen and positive hepatitis B core immunoglobulin G (IgG) antibody. He presented with acute hepatitis, and workup showed features of hepatitis B reactivation, but the extent of reactivation was not adequate to explain the presentation, hence investigations were pursued. This led the way to the diagnosis of a combined hepatitis B reactivation and drug-induced immune hepatitis in this case. He responded promptly to the withdrawal of the agent and steroids. On follow-up, his liver function panel had significantly improved. This case is very unique in two aspects. First, to our knowledge, there is only one case reported of pembrolizumab-induced hepatitis B reactivation. In addition, our patient also had immune-mediated hepatitis induced by pembrolizumab. It is very rare to have a combination of these two presentations to be seen in a patient at the same time. Pembrolizumab-induced immune hepatitis can coexist with hepatitis B reactivation following therapy with this agent.
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Affiliation(s)
- Shanker Kundumadam
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Bashar Mohamad
- Gastroenterology and Hepatology, Wayne State University, Detroit, USA
| | - Arun Muthusamy
- Gastroenterology and Hepatology, Cedar Valley Digestive Health Center, Iowa, USA
| | - Pradeep R Kathi
- Internal Medicine/Gastroenterology, University of Arizona, Tucson, USA
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Regev A, Avigan MI, Kiazand A, Vierling JM, Lewis JH, Omokaro SO, Di Bisceglie AM, Fontana RJ, Bonkovsky HL, Freston JW, Uetrecht JP, Miller ED, Pehlivanov ND, Haque SA, Harrison MJ, Kullak-Ublick GA, Li H, Patel NN, Patwardhan M, Price KD, Watkins PB, Chalasani NP. Best practices for detection, assessment and management of suspected immune-mediated liver injury caused by immune checkpoint inhibitors during drug development. J Autoimmun 2020; 114:102514. [DOI: 10.1016/j.jaut.2020.102514] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
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Prognostic role of gamma-glutamyl transferase in metastatic melanoma patients treated with immune checkpoint inhibitors. Cancer Immunol Immunother 2020; 70:1089-1099. [PMID: 33113003 DOI: 10.1007/s00262-020-02768-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hepatic immune-related adverse events (irAE) including elevated liver function tests (transaminases) occur in 1.4-22.3% of melanoma patients receiving immune checkpoint inhibitors (ICPI) and constitute a potentially serious toxicity that is challenging to treat. In contrast to the liver transaminases alanine aminotransferase (ALT) and aspartate aminotransferase (AST), only little is known about the frequency and impact of gamma-glutamyl transferase (GGT) elevations. METHODS GGT determined prior to and during therapy of metastatic melanoma patients treated with ICPI were retrospectively assessed in two independent cohorts (PD-1: n = 218, Ipi + Nivo: n = 148). Overall survival (OS) and best objective response were analyzed according to baseline and immune-related GGT (irGGT) elevations during treatment. RESULTS In multivariate analysis, OS was reduced in patients with elevated baseline GGT (PD-1 group: hazard ratio [HR] 1.76, p = .0073; Ipi + Nivo group: HR 1.77, p = .032). Immune-related GGT elevation was recorded in 17% (PD-1 group) and 38.5% (Ipi + Nivo group). Of these patients, the majority (81 and 68%, respectively) had normal ALT and AST and showed no clinical signs of hepatotoxicity. Patients who experienced irGGT elevation had superior response (PD-1 group: odds ratio [OR] 3.57, p = .00072; Ipi + Nivo group: OR 1.74, p = .12) and OS (PD-1 group: HR 0.37, p = .0016; Ipi + Nivo group: HR 0.33, p = .00050). CONCLUSIONS The frequency of hepatic irAE is currently underestimated. The addition of the sensitive enzyme GGT to the laboratory panel before and during therapy with ICPI allows to detect two to three times more patients developing hepatic or hepatobiliary toxicity than known so far. Immune-related GGT elevations correlate with response and favorable survival. Precis for use in the Table of Contents The frequency of hepatotoxicity under immune checkpoint blockade is currently underestimated. We suggest the addition of gamma-glutamyl transferase to the laboratory panel in checkpoint inhibitor patients for the detection of hepatobiliary toxicity.
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Durrechou Q, Domblides C, Sionneau B, Lefort F, Quivy A, Ravaud A, Gross-Goupil M, Daste A. Management of Immune Checkpoint Inhibitor Toxicities. Cancer Manag Res 2020; 12:9139-9158. [PMID: 33061607 PMCID: PMC7533913 DOI: 10.2147/cmar.s218756] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/07/2020] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have radically changed the clinical outcome of several cancers with durable responses. CTLA-4 (cytotoxic T lymphocyte antigen-4), PD-1 (programmed cell death protein 1) or PDL-1 (programmed cell death ligand protein 1) represent ICIs that can be used as monotherapy or in combination with other agents. The toxicity p\rofiles of ICIs differ from the side effects of cytotoxic agents and come with new toxicities like immune-related adverse events. Typically, these toxicities occur in all organs. However, the main organs affected are the skin, digestive, hepatic, lungs, rheumatologic, and endocrine. Most of the immune toxicity that occurs is low grade but some more severe toxicities can occur that require a rapid diagnosis and appropriate treatment. The recognition of symptoms by physicians and patient is necessary to resolve them rapidly and adapt treatment to allow the toxicity to resolve.
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Affiliation(s)
- Quentin Durrechou
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Charlotte Domblides
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France.,ImmunoConcEpt, CNRS UMR 5164, Bordeaux University, Bordeaux 33076, France
| | - Baptiste Sionneau
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Felix Lefort
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Amandine Quivy
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Alain Ravaud
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Marine Gross-Goupil
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Amaury Daste
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
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Immune Related Adverse Events: Classification and Management Approaches in Advanced Kidney Cancer. ACTA ACUST UNITED AC 2020; 26:432-440. [PMID: 32947311 DOI: 10.1097/ppo.0000000000000473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Recent therapeutic advancements have incorporated immune checkpoint inhibitors (ICIs) into the management of metastatic renal cell carcinoma. Pivotal phase III trials have resulted in Food and Drug Administration approval for anti-programmed death 1/programmed death ligand 1 ICIs, either in combination with anti-cytotoxic T-lymphocyte antigen 4 ICIs or with vascular endothelial growth factor-directed targeted therapies, as standard-of-care frontline regimens. Immune checkpoint inhibitors offer improved clinical outcomes when compared to previous treatment options. However, these agents also present unique toxicity profiles collectively referred to as immune-related adverse events. Common immune-related adverse events include colitis, hepatitis, dermatitis, and thyroiditis. Rare toxicities, such as myocarditis and pneumonitis, have the potential for causing severe harm. Herein, we provide a case-based discussion of how to identify, grade, and manage irAEs in metastatic renal cell carcinoma.
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Park H, Hatabu H, Ricciuti B, Aijazi SJ, Awad MM, Nishino M. Immune-related adverse events on body CT in patients with small-cell lung cancer treated with immune-checkpoint inhibitors. Eur J Radiol 2020; 132:109275. [PMID: 32949913 DOI: 10.1016/j.ejrad.2020.109275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/28/2020] [Accepted: 09/06/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE Investigate the incidence and imaging characteristics of radiologically-evident immune-related adverse events (irAEs) on body CT in patients with small-cell lung cancer (SCLC) treated with immune-checkpoint inhibitors. METHODS The study included 53 patients with relapsed/refractory SCLC (27 men, 26 women) treated with PD-1/PD-L1 inhibitors alone or in combination with CTLA-4 inhibition, who had baseline and at least one follow-up body CT during therapy. Body CT scans were reviewed to detect and characterize organ-specific irAEs including thyroiditis, pneumonitis, hepatitis, pancreatitis, enteritis, and colitis. RESULTS Nineteen patients (36 %) developed radiologically-evident irAEs. The median time from therapy initiation to irAE onset was 7.1 weeks. Pneumonitis and colitis were most common, noted in 9 patients (17 %) each. Seven colitis cases demonstrated pancolitis, and two cases showed segmental colitis associated with diverticulosis. The common radiographic patterns of pneumonitis were acute interstitial pneumonia (AIP)/acute respiratory distress syndrome (ARDS) pattern (n = 4) and cryptogenic organizing pneumonia (COP) pattern (n = 3). Other irAEs included thyroiditis (n = 3), enteritis (n = 2), hepatitis (n = 1), and pancreatitis (n = 1). Older age (p = 0.03) and prior radiotherapy to any organ (p = 0.03) was associated with overall irAEs. Prior chest radiotherapy was significantly associated with pneumonitis or thyroiditis (p = 0.0004). CONCLUSION Radiologically-evident irAEs were noted on body CT in 36 % of patients with SCLC treated with immune-checkpoint inhibitors. Colitis and pneumonitis were most common. Prior chest radiotherapy was a predictor of the development of both pneumonitis and thyroiditis. Awareness of risk factors and CT findings of irAEs is important for early detection and accurate diagnosis of potentially serious immunotherapy toxicities.
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Affiliation(s)
- Hyesun Park
- Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA; Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Biagio Ricciuti
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Safiya J Aijazi
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Mark M Awad
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Mizuki Nishino
- Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA; Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Pourvaziri A, Parakh A, Biondetti P, Sahani D, Kambadakone A. Abdominal CT manifestations of adverse events to immunotherapy: a primer for radiologists. Abdom Radiol (NY) 2020; 45:2624-2636. [PMID: 32451672 DOI: 10.1007/s00261-020-02531-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Immunotherapy is a rapidly growing field within oncology and is being increasingly used in the management of several malignancies. Due to their unique mechanism of action on the immune system and neoplastic cells, the response pattern and adverse events of this novel therapy are distinct from conventional systemic therapies. Accordingly, the imaging appearances following immunotherapy including adverse events are unique and at times perplexing. Imaging is integral to management of patients on immunotherapeutic agents and a thorough understanding of its mechanism, response patterns and adverse events is crucial for precise interpretation of imaging studies. This review provides a description of the mechanism of action of current immunotherapeutic agents and the organ-wise description of their side effects.
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Affiliation(s)
- Ali Pourvaziri
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Anushri Parakh
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Pierpaolo Biondetti
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Dushyant Sahani
- Department of Radiology, University of Washington, UWMC Radiology RR218, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Avinash Kambadakone
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA.
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Mangan BL, McAlister RK, Balko JM, Johnson DB, Moslehi JJ, Gibson A, Phillips EJ. Evolving insights into the mechanisms of toxicity associated with immune checkpoint inhibitor therapy. Br J Clin Pharmacol 2020; 86:1778-1789. [PMID: 32543711 PMCID: PMC7444794 DOI: 10.1111/bcp.14433] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022] Open
Abstract
Immune checkpoint inhibitors have emerged as a revolutionary treatment option for patients with various types of malignancy. Although these agents afford a significant improvement in outcomes for melanoma and other previously untreatable malignancies, their novel mechanism of action may predispose patients to immune-related adverse effects (irAEs). In the tumour neoantigen environment, these irAEs are due to the activation of the immune system by the blockade of suppressive checkpoints, leading to increases in T-cell activation and proliferation. IrAEs have been reported in almost any organ and at any point in time, even months to years after discontinuation of therapy. Certain populations with distinct physiological changes, genetic risk factors, and specific antigen exposures may be more highly predisposed to develop irAEs. This review discusses the incidence and mechanisms of irAEs and the relationship between host factors and irAE occurrence.
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Affiliation(s)
- Brendan L. Mangan
- Department of PharmacyVanderbilt University Medical CenterNashvilleTNUSA
| | - Renee K. McAlister
- Department of PharmacyVanderbilt University Medical CenterNashvilleTNUSA
| | - Justin M. Balko
- Department of Pathology, Microbiology and ImmunologyVanderbilt University Medical CenterNashvilleTNUSA
- Breast Cancer Research ProgramVanderbilt University Medical CenterNashvilleTNUSA
- Cancer Biology ProgramVanderbilt University Medical CenterNashvilleTNUSA
| | - Douglas B. Johnson
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Javid J. Moslehi
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Andrew Gibson
- Institute for Immunology and Infectious DiseasesMurdoch UniversityMurdochWAAustralia
| | - Elizabeth J. Phillips
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Department of Pathology, Microbiology and ImmunologyVanderbilt University Medical CenterNashvilleTNUSA
- Department of PharmacologyVanderbilt University Medical CenterNashvilleTNUSA
- Institute for Immunology and Infectious DiseasesMurdoch UniversityMurdochWAAustralia
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Das JP, Postow MA, Friedman CF, Do RK, Halpenny DF. Imaging findings of immune checkpoint inhibitor associated pancreatitis. Eur J Radiol 2020; 131:109250. [PMID: 32905952 DOI: 10.1016/j.ejrad.2020.109250] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/21/2020] [Accepted: 08/16/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe contrast-enhanced computed tomography (CECT), 18-Fluorine (18F)-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT and magnetic resonance imaging (MRI) findings of immune checkpoint inhibitor (ICI) associated pancreatitis in patients undergoing immunotherapy for solid malignant tumours. METHOD In this retrospective study, 25 patients with clinical and/or biochemical evidence of pancreatitis who underwent CECT, MRI and 18F-FDG-PET/CT while being treated with ICIs were included. Imaging features of acute pancreatitis included: pancreatic enlargement, heterogeneous enhancement, peripancreatic stranding, fluid collection, pseudocyst, necrosis, atrophy and calcification. 18F-FDG PET/CT imaging was reviewed for pattern of abnormally increased pancreatic FDG uptake. ICI-associated pancreatitis diagnosis was based on clinical, imaging and biochemical findings. RESULTS Imaging findings of ICI-associated pancreatitis included diffuse (n = 14) or focal (n = 11) pancreatic enlargement; heterogenous enhancement (n = 21); focal (n = 9) or diffuse (n = 15) peripancreatic infiltration on CECT and MRI. A pattern consistent with acute interstitial pancreatitis was present in 20/25 (80 %) patients, and a pattern consistent with autoimmune pancreatitis in 4/25 (16 %). A mixed pattern was present in one patient (4%). No patient developed necrotizing pancreatitis or a pseudocyst. The CT severity index was < 3 in all patients, consistent with mild pancreatitis. Focal pancreatic FDG uptake was noted in 2/3 (66 %) of patients. Acute imaging findings resolved with treatment in all 25 patients. Pancreatic atrophy developed in 11/25 (44 %). CONCLUSIONS ICI-associated pancreatitis typically presents as either focal or diffuse acute interstitial pancreatitis. Post-pancreatitis atrophy is common. The ICI-associated pancreatitis cases in our study were mild, managed conservatively and did not result in local acute complications.
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Affiliation(s)
- Jeeban P Das
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Michael A Postow
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Claire F Friedman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Richard K Do
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Darragh F Halpenny
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of severe gastrointestinal and hepatic toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6129-6143. [PMID: 32856210 DOI: 10.1007/s00520-020-05707-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Immune-related adverse events (IrAEs) affecting the gastrointestinal (GI) tract and liver are among the most frequent and most severe inflammatory toxicities from contemporary immunotherapy. Inflammation of the colon and or small intestines (entero)colitis is the single most common GI IrAE and is an important cause of delay of discontinuation of immunotherapy. The severity of these GI IrAEs can range from manageable with symptomatic treatment alone to life-threatening complications, including perforation and liver failure. The frequency and severity of GI IrAEs is dependent on the specific immunotherapy given, with cytotoxic T lymphocyte antigen (CTLA)-4 blockade more likely to induce severe GI IrAEs than blockade of either programmed cell death protein 1 (PD-1) or PD-1 ligand (PD-L1), and combination therapy showing the highest rate of GI IrAEs, particularly in the liver. To date, we have minimal prospective data on the appropriate diagnosis and management of GI IrAEs, and recommendations are based largely on retrospective data and expert opinion. Although clinical diagnoses of GI IrAEs are common, biopsy is the gold standard for diagnosis of both immunotherapy-induced enterocolitis and hepatitis and can play an important role in excluding competing, though less common, diagnoses and ensuring optimal management. GI IrAEs typically respond to high-dose corticosteroids, though a significant fraction of patients requires secondary immune suppression. For colitis, both TNF-α blockade with infliximab and integrin inhibition with vedolizumab have proved highly effective in corticosteroid-refractory cases. Detailed guidelines have been published for the management of low-grade GI IrAEs. In the setting of more severe toxicities, involvement of a GI specialist is generally recommended. The purpose of this review is to survey the available literature and provide management recommendations focused on the GI specialist.
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De Martin E, Michot JM, Rosmorduc O, Guettier C, Samuel D. Liver toxicity as a limiting factor to the increasing use of immune checkpoint inhibitors. JHEP Rep 2020; 2:100170. [PMID: 33205034 PMCID: PMC7648167 DOI: 10.1016/j.jhepr.2020.100170] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) improve clinical outcomes in patients suffering from different types of cancer. Liver toxicity is one of the immune-related adverse events associated with immunotherapy; although not common, its management is challenging as it is extremely heterogeneous in terms of presentation and severity. Differences in the development and evolution of ICI-related toxicity in healthy or cirrhotic livers have not yet been elucidated. Assessing causality is key to diagnosing ICI-induced liver toxicity; liver biopsies can assist not only in the differential diagnosis but also in assessing the severity of histological liver damage. The current classification of severity overestimates the grade of liver injury and needs to be revised to reflect the views of hepatologists. Spontaneous improvements in ICI-related liver toxicity have been reported, so corticosteroid therapy should probably be individualised not systematic. The reintroduction of ICIs in a patient with previous immune-mediated hepatitis may be possible, but the risk/benefit ratio should be considered, as the risk factors for hepatitis recurrence are currently unclear. The management of these patients, requiring a balance between efficacy, toxicity and specific treatments, necessitates multidisciplinary collaboration. The incidence of immune-related liver toxicity will continue to rise based on the increasing use of ICIs for most cancers, mandating improved understanding and management of this complication.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AMA, anti-mitochondrial antibodies
- ANA, anti-nuclear antibodies
- ASMA, anti-smooth muscles antibodies
- AST, aspartate aminotransferase
- CTLA-4, cytotoxic T lymphocyte-associated protein 4
- Corticosteroid therapy
- DCR, disease control rate
- DILI, drug-induced liver injury
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- ICI, immune checkpoint inhibitor
- INR, international normalised ratio
- Immune-mediated hepatitis
- Immunotherapy
- Liver biopsy
- MMF, mycophenolate mofetil
- ORR, objective response rate
- OS, overall survival
- PD-1, programmed cell death 1
- PD-L1-2, programmed cell death ligands 1-2
- PFS, progression-free survival
- TKI, tyrosine kinase inhibitor
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
- anti-LC1, anti-liver cytosol type-1 antibodies
- anti-LKM, anti-liver-kidney microsomal antibodies
- anti-SLA, anti-soluble liver antigen antibodies
- irAE, immune-related adverse event
- trAE, treatment-related adverse event
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Affiliation(s)
- Eleonora De Martin
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France
| | - Jean-Marie Michot
- Département d'innovation thérapeutique et d'Essais Précoces (DITEP), Institut Gustave-Roussy, Université Paris Saclay, Villejuif, France
| | - Olivier Rosmorduc
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France.,Sorbonne-Université
| | - Catherine Guettier
- AP-HP Hôpital Bicêtre, Laboratoire Anatomie Pathologique, Le Kremlin-Bicêtre, France, Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France
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Al-Jundi M, Thakur S, Gubbi S, Klubo-Gwiezdzinska J. Novel Targeted Therapies for Metastatic Thyroid Cancer-A Comprehensive Review. Cancers (Basel) 2020; 12:E2104. [PMID: 32751138 PMCID: PMC7463725 DOI: 10.3390/cancers12082104] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/22/2020] [Accepted: 07/25/2020] [Indexed: 12/18/2022] Open
Abstract
The knowledge on thyroid cancer biology has grown over the past decade. Thus, diagnostic and therapeutic strategies to manage thyroid cancer are rapidly evolving. With new insights into tumor biology and cancer genetics, several novel therapies have been approved for the treatment of thyroid cancer. Tyrosine kinase inhibitors (TKIs), such as lenvatinib and sorafenib, have been successfully utilized for the treatment of radioactive iodine (RAI)-refractory metastatic differentiated thyroid cancer (DTC). In addition, pretreatment with mitogen-activated protein kinase (MAPK) inhibitors (trametinib and selumetinib) has been shown to restore RAI avidity in previously RAI-refractory DTCs. Local therapies, such as external beam radiation and radiofrequency/ethanol ablation, have also been employed for treatment of DTC. Vandetanib and cabozantinib are the two TKIs currently approved by the Food and Drug Administration (FDA) for the treatment of medullary thyroid cancer (MTC). Other novel therapies, such as peptide receptor radionuclide therapy and carcinoembryonic antigen (CEA) vaccine, have also been utilized in treating MTC. Ongoing trials on selective rearranged-during-transfection (RET) protooncogene inhibitors, such as LOXO-292 and BLU-667, have demonstrated promising results in the treatment of metastatic MTC resistant to non-selective TKIs. The FDA-approved BRAF/MEK inhibitor combination of dabrafenib and trametinib has revolutionized treatment of BRAFV600E mutation positive anaplastic thyroid cancer. Several other emerging classes of medications, such as gene fusion inhibitors and immune checkpoint inhibitors, are being actively investigated in several clinical trials. In this review, we describe the molecular landscape of thyroid cancer and novel targeted therapies and treatment combinations available for the treatment of metastatic thyroid cancer.
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Affiliation(s)
| | | | | | - Joanna Klubo-Gwiezdzinska
- Thyroid Tumors and Functional Thyroid Disorders Section, Metabolic Disease Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20814, USA; (M.A.-J.); (S.T.); (S.G.)
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Qu J, Wang L, Jiang M, Zhao D, Wang Y, Zhang F, Li J, Zhang X. A Review About Pembrolizumab in First-Line Treatment of Advanced NSCLC: Focus on KEYNOTE Studies. Cancer Manag Res 2020; 12:6493-6509. [PMID: 32801888 PMCID: PMC7395702 DOI: 10.2147/cmar.s257188] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022] Open
Abstract
Lung cancer is currently the malignant tumor with the highest incidence and mortality in the world, while non-small cell lung cancer (NSCLC) is the most common pathological type of lung caner. In the past few decades, the only treatment options available for advanced NSCLC patients have been targeted therapy or chemotherapy, but these therapies are inevitably tolerated by tumors. The discovery of immune checkpints that mediate the immune escape of tumor cells have been promoting a series of immune checkpoint inhibitors to be used in cancer treatment and achieved great results. Among them, pembrolizumab is currently the only PD-1 inhibitor approved for first-line treatment of NSCLC, whether it is monotherapy or combination therapy, for creditable performance in KEYNOTE studies. In this review, we systematically integrate the latest series of clinical trial results, pharmacological mechanisms, adverse events (AEs) and predictive biomarkers in the first-line treatment of NSCLC. We hope pembrolizumab could become a better choice for more clinicians and benefit more patients with advanced NSCLC.
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Affiliation(s)
- Jialin Qu
- Department of Medical Oncology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, People's Republic of China
| | - Li Wang
- Department of Medical Oncology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, People's Republic of China
| | - Man Jiang
- Department of Medical Oncology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, People's Republic of China
| | - Deze Zhao
- Department of Medical Oncology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, People's Republic of China
| | - Yuyang Wang
- Department of Medical Oncology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, People's Republic of China
| | - Feng Zhang
- Department of Medical Oncology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, People's Republic of China
| | - Jing Li
- Department of Medical Oncology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, People's Republic of China
| | - Xiaochun Zhang
- Department of Medical Oncology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, People's Republic of China
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Deng J, Chen X, Sun H, Liu Y, Li W, Chen B, Zhao S, Jia K, Wang H, Guo H, Jiang M, Xu Y, He Y, Zhou C. Hypoproteinemia being a manifestation of immunotherapy-related liver dysfunction. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:889. [PMID: 32793733 PMCID: PMC7396795 DOI: 10.21037/atm-20-4980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/09/2020] [Indexed: 11/06/2022]
Abstract
Immunotherapy has changed the pattern of treatment in cancer. The interaction between programmed death-1 (PD-1) and programmed death-ligand 1 (PD-L1) inhibits the activation of T cells, and PD-1/PD-L1 inhibitors can increase the immune response to cancer cells by inducing the immune cells, which has become an important clinical method to treat cancer. However, the alteration in the activation of T cells might lead to misidentification between the body's own cells and tumor cells and induce immune-related adverse events (IRAEs), such as pneumonitis, liver dysfunction, rash, colitis, nephritis, and endocrinopathies. And the IRAEs might lead to serious consequences. Studies have reported that PD-1/PD-L1 inhibitor-related hepatotoxicity is one of these adverse events. Most of the studies reported that hepatitis resulting from PD-1 inhibitor was manifested as elevated liver enzymes and bilirubin. Quite a few patients experienced lower degree of hepatotoxicity treated with checkpoint inhibitors, which indicated that it was necessary to focus on immunotherapy-related liver dysfunction. Here, we report a case of immunotherapy-related liver dysfunction with hypoproteinemia as the first manifestation under the treatment of PD-1 inhibitors combined with chemotherapy. This case suggests that hypoproteinemia was one of the manifestations of immunotherapy-related liver dysfunction, which helps us better understand the immunotherapy-related disease.
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Affiliation(s)
- Juan Deng
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
- Tongji University, Shanghai, China
| | - Xiaoxia Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
| | - Hui Sun
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
| | - Yu Liu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
- Tongji University, Shanghai, China
| | - Wei Li
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
| | - Bin Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
| | - Sha Zhao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
- Tongji University, Shanghai, China
| | - Keyi Jia
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
- Tongji University, Shanghai, China
| | - Hao Wang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
- Tongji University, Shanghai, China
| | - Haoyue Guo
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
- Tongji University, Shanghai, China
| | - Minlin Jiang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
- Tongji University, Shanghai, China
| | - Yi Xu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
- Tongji University, Shanghai, China
| | - Yayi He
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
| | - Caicun Zhou
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai, China
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Li B, Yan C, Zhu J, Chen X, Fu Q, Zhang H, Tong Z, Liu L, Zheng Y, Zhao P, Jiang W, Fang W. Anti-PD-1/PD-L1 Blockade Immunotherapy Employed in Treating Hepatitis B Virus Infection-Related Advanced Hepatocellular Carcinoma: A Literature Review. Front Immunol 2020; 11:1037. [PMID: 32547550 PMCID: PMC7270402 DOI: 10.3389/fimmu.2020.01037] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 04/29/2020] [Indexed: 12/24/2022] Open
Abstract
Hepatitis B virus (HBV) infection is regarded as the main etiological risk factor in the process of hepatocellular carcinoma (HCC), as it promotes an immunosuppressive microenvironment that is partially mediated by the programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) signaling pathway. The tumor microenvironment (TME) of HBV-related HCC is indeed more immunosuppressive than microenvironments not associated with viruses. And compared to TME in hepatitis C virus (HCV) infected HCC, TME of HBV-related HCC is less vascularized and presents different immune components resulting in similar immunosuppression. However, few studies are focusing on the specific side effects and efficacy of PD-1/PD-L1 blockade immunotherapy in HBV-related HCC patients, as well as on the underlying mechanism. Herein, we reviewed the basic research focusing on potential TME alteration caused by HBV infection, especially in HCC patients. Moreover, we reviewed PD-1/PD-L1 blockade immunotherapy clinical trials to clarify the safety and efficacy of this newly developed treatment in the particular circumstances of HBV infection. We found that patients with HBV-related HCC displayed an acceptable safety profile similar to those of non-infected HCC patients. However, we could not determine the antiviral activity of PD-1/PD-L1 blockade because standard anti-viral therapies were conducted in all of the current clinical trials, which made it difficult to distinguish the potential influence of PD-1/PD-L1 blockade on HBV infection. Generally, the objective response rates (ORRs) of PD-1/PD-L1 blockade immunotherapy did not differ significantly between virus-positive and virus-negative patients, except that disease control rates (DCRs) were obviously lower in HBV-infected HCC patients.
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Affiliation(s)
- Bin Li
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Cong Yan
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiamin Zhu
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaobing Chen
- Department of Oncology, Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Qihan Fu
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hangyu Zhang
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhou Tong
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lulu Liu
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi Zheng
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Peng Zhao
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weiqin Jiang
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weijia Fang
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Immune checkpoint inhibition for non-small cell lung cancer in patients with pulmonary tuberculosis or Hepatitis B: Experience from a single Asian centre. Lung Cancer 2020; 146:145-153. [PMID: 32540557 DOI: 10.1016/j.lungcan.2020.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/09/2020] [Accepted: 05/12/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The importance of immune-checkpoint inhibitors (ICI) can no longer be understated since its move to front-line treatment in non-small cell lung cancer (NSCLC) in recent years. However, the safety and efficacy of ICI in special populations such as those with infections like tuberculosis (TB) and hepatitis B (HBV) remain unknown as they are routinely excluded from clinical trials. METHODS Records of patients with advanced NSCLC who were treated with ICI from January 2014 to June 2019 at a single Asian centre were reviewed. Those with a history of HBV and/or TB were selected. In this group, safety and treatment outcomes including overall survival (OS), progression-free survival (PFS) and response rate were reported and compared against control. RESULTS 191 patients received ICI, 47 (24.6%) had a history of TB/HBV. The median PFS in those with a history of TB/HBV was 5.7 months (95% CI 3.9-7.6), compared to 3.1 months (95% CI 2.4-3.8) in control (HR 0.61, 95% CI 0.39-0.93, p = 0.021). Median OS was 15.6 months (95% CI 10.2-21.0) compared to 11.1 months (95% CI 7.6-14.7 months) in the control group (HR 0.58, 95% CI 0.34-0.99, p = 0.046). Adverse events of any grade (G) were similar in both groups; slightly more patients with TB/HBV experienced G3 or higher adverse events. Four patients developed TB after initiation of ICI, none with previously documented TB experienced reactivation. Of the 42 patients with a history of HBV, eight had inactive chronic HBV and six had detectable viral load. None of the 34 patients who were previously exposed to HBV had reactivation. CONCLUSION The use of ICI appears to be safe and efficacious in patients with TB/HBV infection. Prospective studies are required to identify those at risk in order to optimise care to these groups of patients.
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Ogawa K, Kaneda H, Kawamoto T, Tani Y, Izumi M, Matsumoto Y, Sawa K, Suzumura T, Watanabe T, Mitsuoka S, Asai K, Kawaguchi T. Early-onset meningitis associated with atezolizumab treatment for non-small cell lung cancer: case report and literature review. Invest New Drugs 2020; 38:1901-1905. [PMID: 32399862 DOI: 10.1007/s10637-020-00947-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/07/2020] [Indexed: 12/19/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have improved the overall survival of many patients with advanced cancers. However, unlike cytotoxic and targeted drugs, ICIs may cause various immune-related adverse events (irAEs). Among these irAEs, autoimmune meningitis is very rare. Here, we report a case of early-onset, atezolizumab-induced meningitis after administration of one dose of atezolizumab. A 56-year-old man with lung adenocarcinoma had received seventh-line treatment with atezolizumab when he experienced dysarthria. Blood examinations, including the measurement of electrolytes, glucose, and organ functions, were unremarkable, but enhanced head magnetic resonance imaging T1-weighted images showed meningeal enhancement. Although cerebral spinal fluid (CSF) examinations revealed elevated lymphocyte and protein levels, no cancer cells were detected in the CSF. CSF cultures and serological tests, including polymerase chain reaction for herpes simplex virus, were negative. The patient was therefore diagnosed with atezolizumab-triggered autoimmune meningitis. With steroid treatment, the patient's clinical and neurological state improved immediately and he recovered to baseline conditions. Prompt diagnosis and therapeutic intervention are essential for the effective treatment of autoimmune meningitis.
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Affiliation(s)
- Koichi Ogawa
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Hiroyasu Kaneda
- Department of Clinical Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan.
| | - Tamaki Kawamoto
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Yoko Tani
- Department of Clinical Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Motohiro Izumi
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Yoshiya Matsumoto
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Kenji Sawa
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Tomohiro Suzumura
- Department of Clinical Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Tetsuya Watanabe
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Shigeki Mitsuoka
- Department of Clinical Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
| | - Tomoya Kawaguchi
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan.,Department of Clinical Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, 545-8585, Osaka, Japan
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68
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Thomas R, Sebastian B, George T, Majeed NF, Akinola T, Laferriere SL, Braschi-Amirfarzan M. A review of the imaging manifestations of immune check point inhibitor toxicities. Clin Imaging 2020; 64:70-79. [PMID: 32334270 DOI: 10.1016/j.clinimag.2020.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/24/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
The past decade has witnessed a paradigm shift in cancer therapy owing to the introduction of immune checkpoint inhibitors (ICIs) and it is now commonplace for radiologists to image patients on therapy with these agents. The purpose of this review is to detail the mechanism, radiological manifestations and clinical significance of ICI related toxicities, according to the organ system involved. ICI related toxicities that have known imaging manifestations include colitis, enterocolitis, pancreatitis, hepatitis, endocrine toxicities, pneumonitis, cardiovascular toxicity and musculoskeletal toxicity. These toxicities may be acute, recurrent or chronic in nature. Radiologists must be aware of the imaging features and clinical significance of these toxicities in order to effectively participate in personalized cancer therapy.
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Affiliation(s)
- Richard Thomas
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, United States of America; Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Ave, Boston 02215, MA, United States of America.
| | - Bibin Sebastian
- Department of Radiology, Government Medical College, Kozhikode 673008, Kerala, India
| | - Tom George
- Department of Radiology, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Noor Fatima Majeed
- Department of Radiology, Beth Israel Lahey Health, Lahey Health Medical Center, Tufts University School of Medicine, Burlington, MA 01805, United States of America.
| | - Temilola Akinola
- Department of Radiology, Beth Israel Lahey Health, Lahey Health Medical Center, Tufts University School of Medicine, Burlington, MA 01805, United States of America.
| | - Shawn L Laferriere
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, United States of America; Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Ave, Boston 02215, MA, United States of America; Department of Radiology, Cary Medical Center, 163 Van Buren Rd, Caribou, ME 04736, United States of America.
| | - Marta Braschi-Amirfarzan
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, United States of America; Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Ave, Boston 02215, MA, United States of America; Department of Radiology, Beth Israel Lahey Health, Lahey Health Medical Center, Tufts University School of Medicine, Burlington, MA 01805, United States of America.
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69
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Levine I, Kalisz K, Smith DA, Tirumani SH, Ramaiya NH, Alessandrino F. Update on Hodgkin lymphoma from a radiologist's perspective. Clin Imaging 2020; 65:65-77. [PMID: 32361412 DOI: 10.1016/j.clinimag.2020.04.021] [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: 12/09/2019] [Revised: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
Recent advances in the management of Hodgkin lymphoma, due to new staging and response assessment systems as well as new therapies, have redefined the role of imaging for this disease. The purpose of this article is to provide radiologists with an update on the current role of imaging in Hodgkin lymphoma from diagnosis to assessment of treatment response, in view of the new staging and response assessment system and current treatment strategies.
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Affiliation(s)
- Isaac Levine
- Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Kevin Kalisz
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Daniel A Smith
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Sree Harsha Tirumani
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Nikhil H Ramaiya
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Francesco Alessandrino
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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70
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Abu-Sbeih H, Wang Y. Hepatobiliary Adverse Events. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1244:271-276. [PMID: 32301021 DOI: 10.1007/978-3-030-41008-7_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are increasingly used for multiple cancer types. Hepatotoxicity is a reported adverse event of ICI treatment. It can present as asymptomatic elevation of aspartate transaminase and alanine transaminase or symptomatic hepatitis with fever, malaise, and even death in rare cases. The diagnosis of ICI-induced hepatitis is made after exclusion of other etiologies based on medical history, laboratory evaluation, and imaging and histological findings. Treatment of ICI-induced hepatitis consists of ICI discontinuation and immunosuppression in severe cases. Pancreatic injury as asymptomatic lipase elevation or acute pancreatitis-like disease with abdominal pain and evidence on imaging has been documented as a toxicity of ICI therapy. Appropriate treatment of pancreatitis still needs further investigation. Few cases, reports, and series documented cholecystitis and cholangitis as possible adverse events related to ICI therapy as well.
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Affiliation(s)
- Hamzah Abu-Sbeih
- Department of Internal Medicine, University of Missouri, Kansas City, MO, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology & Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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71
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Imaging of Adverse Events Related to Checkpoint Inhibitor Therapy. Diagnostics (Basel) 2020; 10:diagnostics10040216. [PMID: 32294888 PMCID: PMC7235714 DOI: 10.3390/diagnostics10040216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 12/19/2022] Open
Abstract
Immunotherapy with checkpoint inhibitors (ICIs) is becoming standard of practice for an increasing number of cancer types. ICIs enhance T-cell action against the cancer cells. By unbalancing the immune system ICIs may cause dysimmune toxicities, a series of disorders broadly defined immune-related adverse events (irAEs). IrAEs may affect any organ or apparatus and most frequently involve skin, colon, endocrine organs, liver, and lungs. Early identification and appropriate treatment of irAEs can improve patient outcome. The paper aims at reviewing mechanisms of the occurrence of irAEs, the importance of a proper diagnosis and the main pillars of therapy. To provide effective guidance to the comprehension of major irAEs imaging findings will be reviewed.
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72
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Black JR, Goldin RD, Foxton M, Marafioti T, Akarca AU, Pria AD, Brock C, Bower M, Pinato DJ. PD-L1 expressing granulomatous reaction as an on-target mechanism of steroid-refractory immune hepatotoxicity. Immunotherapy 2020; 11:585-590. [PMID: 30943859 DOI: 10.2217/imt-2018-0187] [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: 12/19/2022] Open
Abstract
Immune-related hepatitis is an important toxicity from immune-checkpoint inhibitor therapy, affecting up to 20% of patients on dual cytotoxic T-lymphocyte antigen 4/programmed cell death 1 (CTLA-4/PD-1) inhibitors. The mechanisms underlying this type of drug-induced liver injury are poorly understood. We report the case of a patient with immune-checkpoint inhibitor-related hepatitis where the presence of a diffuse granulomatous, PD-L1-positive infiltrate on liver biopsy correlated with poor response to corticosteroids. Our findings suggest a potential role for activation of the PD-1 pathway within the histiocitic infiltrate as a mechanism of toxicity. Further studies should address the role of macrophages in this patient group characterized by steroid-refractoriness.
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Affiliation(s)
- James Rm Black
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W120HS, UK.,Department of Oncology, Chelsea & Westminster Hospital, 369 Fulham Road, Chelsea, London SW10 9NH, UK
| | - Robert D Goldin
- Department of Cellular Pathology, Imperial College London, Clarence Wing, St Mary's Hospital Campus, Praed St, Paddington, London W2 1NY, UK
| | - Matthew Foxton
- Department of Gastroenterology & Hepatology, Chelsea & Westminster Hospital, 369 Fulham Road, Chelsea, London SW10 9NH, UK
| | - Teresa Marafioti
- Department of Histopathology, University College London, 4th Floor Rockefeller Building, 21 University Street, London WC1E 6DE, UK
| | - Ayse U Akarca
- Department of Histopathology, University College London, 4th Floor Rockefeller Building, 21 University Street, London WC1E 6DE, UK
| | - Alessia Dalla Pria
- Department of Oncology, Chelsea & Westminster Hospital, 369 Fulham Road, Chelsea, London SW10 9NH, UK
| | - Cathryn Brock
- Department of Oncology, Chelsea & Westminster Hospital, 369 Fulham Road, Chelsea, London SW10 9NH, UK
| | - Mark Bower
- Department of Oncology, Chelsea & Westminster Hospital, 369 Fulham Road, Chelsea, London SW10 9NH, UK
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W120HS, UK.,Department of Oncology, Chelsea & Westminster Hospital, 369 Fulham Road, Chelsea, London SW10 9NH, UK
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Dougan M. Gastrointestinal and Hepatic Complications of Immunotherapy: Current Management and Future Perspectives. Curr Gastroenterol Rep 2020; 22:15. [PMID: 32185493 DOI: 10.1007/s11894-020-0752-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Checkpoint inhibitor (CPI) immunotherapy has transformed the treatment of multiple cancers over the past decade, leading to durable remissions, but also to severe inflammatory toxicities. These toxicities, termed immune-related adverse events (irAEs), can affect any organ system in the body, but commonly induce inflammation in barrier organs. Gastrointestinal (GI) and hepatic irAEs are among the most frequent and most severe from contemporary immunotherapies, with inflammation in the colon and or small intestines (entero)colitis as the single most common GI irAE. The aim of this review is to describe the evidence supporting our current understanding of CPI enterocolitis and hepatitis, as well as the management of these entities. RECENT FINDINGS Although most patients who develop enterocolitis recover without long-term GI sequelae, enterocolitis is still an important reason for treatment discontinuation, which, in patients with metastatic cancer, can be a life-threatening outcome. At present, we have almost no prospective, randomized data regarding the management of CPI enterocolitis, and current management algorithms are based on expert opinion and small retrospective studies with a high likelihood of bias. Retrospective studies have defined colonic ulceration as a predictor of colitis responsiveness to corticosteroids, and have defined microscopic colitis as a subtype of CPI enterocolitis with a distinct treatment response. Corticosteroids appear to be effective for 60-70% of patients with CPI enterocolitis, with about a third of patients requiring escalation to a biologic agent such as infliximab or vedolizumab. Yet proper sequencing of these treatments to minimize risk and maximize treatment benefit has not been established, and we do not know how treatment of colitis influences cancer outcomes. CPI enterocolitis and hepatitis are important causes of treatment interruption and discontinue, and significant morbidity in patients undergoing immunotherapy. As guidelines for diagnosis and management rely heavily on expert opinion, we have an urgent need for randomized and prospective trials that use both colitis and cancer outcomes to determine optimal management strategies.
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Affiliation(s)
- Michael Dougan
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Guler E, Smith DA, Somarouthu B, Gujrathi R, Ramaiya NH, Tirumani SH. Overview of imaging findings associated with systemic therapies in advanced epithelial ovarian cancer. Abdom Radiol (NY) 2020; 45:828-841. [PMID: 31396642 DOI: 10.1007/s00261-019-02175-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To provide an overview for radiologists of the systemic agents used in the treatment of advanced epithelial ovarian cancer (EOC) and their associated toxicities. RESULTS EOC is a common gynecological malignancy, with the majority of patients presenting with advanced stage disease at the time of diagnosis. Although primary cytoreductive surgery and chemotherapy are the principal treatments for EOC, recurrence rates of disease remain high. As several molecular targeted therapies have been developed in the last decade, various novel agents have shown efficacy in the treatment of advanced EOC. Advanced EOC will be discussed by outlining the relevant radiological features of toxicities. CONCLUSION Knowledge of the systemic therapies utilized in the treatment of advanced EOC and their associated radiological features is critical in diagnostic image interpretation.
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Affiliation(s)
- Ezgi Guler
- Department of Radiology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Daniel A Smith
- Department of Radiology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Bhanusupriya Somarouthu
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Rahul Gujrathi
- Department of Radiology, Harvard Medical School, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nikhil H Ramaiya
- Department of Radiology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Sree Harsha Tirumani
- Department of Radiology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
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Li Y, Kang X, Wang H, Guo X, Zhou J, Duan L, Si X, Zhang L, Liu X, Qian J, Zhang L. Clinical diagnosis and treatment of immune checkpoint inhibitor-associated adverse events in the digestive system. Thorac Cancer 2020; 11:829-834. [PMID: 32107847 PMCID: PMC7113043 DOI: 10.1111/1759-7714.13338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/11/2020] [Accepted: 01/12/2020] [Indexed: 12/17/2022] Open
Abstract
Immunotherapy for malignant tumors is a hot spot in current research and the treatment of cancer. The activation of programmed cell death receptor-1 (PD-1) and cytotoxic T lymphocyte-associated antigen 4 (CTLA)-4 relevant signaling pathway can inhibit the activation of T lymphocytes. Tumor cells can achieve immune escape by activating this signaling pathway. By inhibiting this signaling pathway, immune-checkpoint inhibitors (ICIs) activate T lymphocytes to clear the tumor cells. Therefore, the adverse effects of ICIs are mainly immune-related adverse events (irAEs). The digestive system, including the gastrointestinal tract and liver which are vital organs of digestion and absorption, metabolism and detoxification, as well as important immune-related organs, is the most commonly affected system of irAEs. This review explains the incidence, clinical features, diagnosis and treatment of liver and gastrointestinal adverse events in ICIs.
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Affiliation(s)
- Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Xiaohui Kang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Hanping Wang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoxiao Guo
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Jiaxin Zhou
- Department of Immunology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Lian Duan
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoyan Si
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Li Zhang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Xiaowei Liu
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Jiaming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Li Zhang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
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Tan B, Li Y, Xu Y, Chen M, Wang M, Qian J. Recognition and management of the gastrointestinal and hepatic immune-related adverse events. Asia Pac J Clin Oncol 2020; 16:95-102. [PMID: 32077625 DOI: 10.1111/ajco.13317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/09/2020] [Indexed: 12/17/2022]
Abstract
Immunotherapy is revolutionizing the treatment paradigm for a broad spectrum of malignancies. However, the immune checkpoint inhibitors also cause a unique set of toxicities. In the digestive system, this has consisted for the most part as colitis and hepatotoxicity, but also include less-common manifestations. Baseline screening, early identification, timely diagnosis, rapid and adequate treatment can significantly minimize the toxicity of immunotherapy and improve prognosis. This article provides a comprehensive review of gastrointestinal and hepatic immune-related toxicities, including incidence, mechanism, clinical manifestation, diagnosis, treatment, and guidelines for resumption of immune checkpoint inhibitor therapy.
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Affiliation(s)
- Bei Tan
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yan Xu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Minjiang Chen
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Mengzhao Wang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Jiaming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
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Choi J, Lee SY. Clinical Characteristics and Treatment of Immune-Related Adverse Events of Immune Checkpoint Inhibitors. Immune Netw 2020; 20:e9. [PMID: 32158597 PMCID: PMC7049586 DOI: 10.4110/in.2020.20.e9] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have been changing the paradigm of cancer treatment. However, immune-related adverse effects (irAEs) have also increased with the exponential increase in the use of ICIs. ICIs can break up the immunologic homeostasis and reduce T-cell tolerance. Therefore, inhibition of immune checkpoint can lead to the activation of autoreactive T-cells, resulting in various irAEs similar to autoimmune diseases. Gastrointestinal toxicity, endocrine toxicity, and dermatologic toxicity are common side effects. Neurotoxicity, cardiotoxicity, and pulmonary toxicity are relatively rare but can be fatal. ICI-related gastrointestinal toxicity, dermatologic toxicity, and hypophysitis are more common with anti- CTLA-4 agents. ICI-related pulmonary toxicity, thyroid dysfunction, and myasthenia gravis are more common with PD-1/PD-L1 inhibitors. Treatment with systemic steroids is the principal strategy against irAEs. The use of immune-modulatory agents should be considered in case of no response to the steroid therapy. Treatment under the supervision of multidisciplinary specialists is also essential, because the symptoms and treatments of irAEs could involve many organs. Thus, this review focuses on the mechanism, clinical presentation, incidence, and treatment of various irAEs.
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Affiliation(s)
- Juwhan Choi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea
| | - Sung Yong Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea
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Abstract
INTRODUCTION We conducted this study to characterize the incidence, clinical features, treatment, and outcomes of immune checkpoint inhibitor (ICI) hepatotoxicity. METHODS Patients who received ICIs (with either single-agent or combination regimens) from January 1, 2010, to March 31, 2018, were identified. Hepatotoxicity was defined as alanine aminotransferase (ALT) >5 times the upper limit of normal (ULN), in the absence of an alternate cause, and categorized as grade 3 (ALT 5-20× ULN) or grade 4 (ALT >20× ULN), according to Common Terminology Criteria for Adverse Events 4.03. RESULTS Among 5,762 patients, 100 (2%) developed hepatotoxicity, occurring in a higher proportion of recipients of combination therapy (9.2%) compared with monotherapy (up to 1.7%, P < 0.001). ICIs were discontinued permanently in 69 and temporarily in 31 patients. Sixty-seven patients received steroids, 10 of whom (14%) had recurrent hepatotoxicity after the steroid taper. Thirty-one patients resumed ICIs after ALT improvement, 8 of whom (26%) developed recurrent hepatotoxicity. Characteristics of liver injury, response to steroids, and outcomes were similar between 38 individuals with and 62 without possible pre-existing liver disease. The severity and outcome of hepatotoxicity due to combination therapy were not significantly different from monotherapy. There were 36 deaths. Two had liver failure at the time of death, both with progression of liver metastases and grade 3 hepatotoxicity. DISCUSSION Clinically significant ICI-related hepatotoxicity was uncommon but led to permanent ICI discontinuation in the majority. ICIs were restarted in a sizable proportion of patients, most of whom did not experience recurrent hepatotoxicity.
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Hsu C, Marshall JL, He AR. Workup and Management of Immune-Mediated Hepatobiliary Pancreatic Toxicities That Develop During Immune Checkpoint Inhibitor Treatment. Oncologist 2020; 25:105-111. [PMID: 32043797 PMCID: PMC7011649 DOI: 10.1634/theoncologist.2018-0162] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/19/2019] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitor treatment has been approved by the U.S. Food and Drug Administration for the treatment of a wide range of cancer types, including hepatocellular carcinoma. Workup and management of immune-mediated hepatitis, pancreatitis, or cholangitis that develops during immune checkpoint inhibitor treatment can be challenging. Immune-mediated hepatitis can be particularly challenging if patients have underlying viral hepatitis or autoimmune hepatitis. Patients with positive hepatitis B virus DNA should be referred to a hepatologist for antiviral therapy prior to immune checkpoint inhibitor treatment. With untreated hepatitis C virus (HCV) and elevated liver enzymes, a liver biopsy should be obtained to differentiate between HCV infection and immune-mediated hepatitis due to anti-programmed cell death protein 1 (PD-1) therapy. If autoimmune serologies are negative, then this supports a case of immune-mediated hepatitis secondary to anti-PD-1 therapy, rather than autoimmune hepatitis. In this case, an empiric steroid therapy is reasonable; however, if the patient does not respond to steroid therapy in 3-5 days, then liver biopsy should be pursued. The incidence of immune checkpoint-induced pancreatitis is low, but when it does occur, diagnosis is not straightforward. Although routine monitoring of pancreatic enzymes is not generally recommended, when pancreatitis is suspected, serum levels of amylase and lipase should be checked. Once confirmed, a steroid or other immunosuppressant (if steroids are contraindicated) should be administered along with close monitoring, and a slow tapering dosage once the pancreatitis is under control. Patients should then be monitored for recurrent pancreatitis. Finally, immune therapy-related cholangitis involves elevated bilirubin and alkaline phosphatase and, once diagnosed, is managed in the same way as immune-mediated hepatitis. KEY POINTS: Immune-mediated hepatitis, pancreatitis, and cholangitis are found in patients receiving or who have previously received immune checkpoint inhibitors. To work up immune-mediated hepatitis, viral, and autoimmune serologies, liver imaging will help to differentiate immune-mediated hepatitis from hepatitis of other etiology. Hepatology consult may be considered in patients with a history of chronic liver disease who developed hepatitis during immune checkpoint inhibitor treatment. Liver biopsy should be considered to clarify the diagnosis for case in which the hepatitis is refractory to steroid or immunosuppressant treatment. Immune-mediated pancreatitis is treated with steroid or other immunosuppressant with a slow tapering and should be monitored for recurrence.
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Affiliation(s)
- Christine Hsu
- MedStar Georgetown Transplant Institute, Pasquerilla Healthcare CenterWashingtonDCUSA
| | - John L. Marshall
- Lombardi Comprehensive Cancer Center, Georgetown UniversityWashingtonDCUSA
| | - Aiwu Ruth He
- Lombardi Comprehensive Cancer Center, Georgetown UniversityWashingtonDCUSA
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Dromain C, Beigelman C, Pozzessere C, Duran R, Digklia A. Imaging of tumour response to immunotherapy. Eur Radiol Exp 2020; 4:2. [PMID: 31900689 PMCID: PMC6942076 DOI: 10.1186/s41747-019-0134-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/08/2019] [Indexed: 02/06/2023] Open
Abstract
A wide range of cancer immunotherapy approaches has been developed including non-specific immune-stimulants such as cytokines, cancer vaccines, immune checkpoint inhibitors (ICIs), and adoptive T cell therapy. Among them, ICIs are the most commonly used and intensively studied. Since 2011, these drugs have received marketing authorisation for melanoma, lung, bladder, renal, and head and neck cancers, with remarkable and long-lasting treatment response in some patients. The novel mechanism of action of ICIs, with immune and T cell activation, leads to unusual patterns of response on imaging, with the advent of so-called pseudoprogression being more pronounced and frequently observed when compared to other anticancer therapies. Pseudoprogression, described in about 2–10% of patients treated with ICIs, corresponds to an increase of tumour burden and/or the appearance of new lesions due to infiltration by activated T cells before the disease responds to therapy. To overcome the limitation of response evaluation criteria in solid tumors (RECIST) to assess these specific changes, new imaging criteria—so-called immune-related response criteria and then immune-related RECIST (irRECIST)—were proposed. The major modification involved the inclusion of the measurements of new target lesions into disease assessments and the need for a 4-week re-assessment to confirm or not confirm progression. The RECIST working group introduced the new concept of “unconfirmed progression”, into the irRECIST. This paper reviews current immunotherapeutic approaches and summarises radiologic criteria to evaluate new patterns of response to immunotherapy. Furthermore, imaging features of immunotherapy-related adverse events and available predictive biomarkers of response are presented.
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Affiliation(s)
- Clarisse Dromain
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
| | - Catherine Beigelman
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Chiara Pozzessere
- Department of Radiology, AUSL Toscana Centro - San Giuseppe Hospital, Empoli, Italy
| | - Rafael Duran
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Antonia Digklia
- Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Czaja AJ. Examining pathogenic concepts of autoimmune hepatitis for cues to future investigations and interventions. World J Gastroenterol 2019; 25:6579-6606. [PMID: 31832000 PMCID: PMC6906207 DOI: 10.3748/wjg.v25.i45.6579] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/25/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multiple pathogenic mechanisms have been implicated in autoimmune hepatitis, but they have not fully explained susceptibility, triggering events, and maintenance or escalation of the disease. Furthermore, they have not identified a critical defect that can be targeted. The goals of this review are to examine the diverse pathogenic mechanisms that have been considered in autoimmune hepatitis, indicate investigational opportunities to validate their contribution, and suggest interventions that might evolve to modify their impact. English abstracts were identified in PubMed by multiple search terms. Full length articles were selected for review, and secondary and tertiary bibliographies were developed. Genetic and epigenetic factors can affect susceptibility by influencing the expression of immune regulatory genes. Thymic dysfunction, possibly related to deficient production of programmed cell death protein-1, can allow autoreactive T cells to escape deletion, and alterations in the intestinal microbiome may help overcome immune tolerance and affect gender bias. Environmental factors may trigger the disease or induce epigenetic changes in gene function. Molecular mimicry, epitope spread, bystander activation, neo-antigen production, lymphocytic polyspecificity, and disturbances in immune inhibitory mechanisms may maintain or escalate the disease. Interventions that modify epigenetic effects on gene expression, alter intestinal dysbiosis, eliminate deleterious environmental factors, and target critical pathogenic mechanisms are therapeutic possibilities that might reduce risk, individualize management, and improve outcome. In conclusion, diverse pathogenic mechanisms have been implicated in autoimmune hepatitis, and they may identify a critical factor or sequence that can be validated and used to direct future management and preventive strategies.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, United States
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82
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Reddy CA, Schneider BJ, Brackett LM, Tai AW. Nivolumab-induced large-duct cholangiopathy treated with ursodeoxycholic acid and tocilizumab. Immunotherapy 2019; 11:1527-1531. [PMID: 31789069 DOI: 10.2217/imt-2019-0121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Immune checkpoint inhibitor therapy has become a cornerstone in the management of many oncologic diseases. Although it is well tolerated in most patients, a wide spectrum of adverse events has been described as a result of immune system alteration. We present a case of a woman with metastatic bronchogenic adenocarcinoma who was initially thought to have immune-mediated hepatitis, but eventually discovered to have a rarely described immune-mediated cholangiopathy. Her cholangiopathy appeared to stabilize following ursodeoxycholic acid and tocilizumab after several lines of guideline-directed therapy. Awareness of this unique toxicity following immune checkpoint inhibitor, and potential treatment options may help clinicians manage this rare but serious complication.
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Affiliation(s)
- Chanakyaram A Reddy
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Bryan J Schneider
- Division of Hematology & Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Lindsay M Brackett
- Division of Hematology & Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Andrew W Tai
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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Ibraheim H, Perucha E, Powell N. Pathology of immune-mediated tissue lesions following treatment with immune checkpoint inhibitors. Rheumatology (Oxford) 2019; 58:vii17-vii28. [PMID: 31816081 PMCID: PMC6900915 DOI: 10.1093/rheumatology/kez465] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/05/2019] [Indexed: 01/03/2023] Open
Abstract
Immune check point inhibitor (CPI) therapy has revolutionized treatment paradigms for several cancers, but at the cost of triggering a diverse spectrum of immune-mediated injury to non-cancer tissues. The complex biology of these toxicities remains incompletely understood, partly because tissue acquisition from affected areas can be challenging to retrieve, thus hindering development of targeted therapy. Here, we review the literature describing pathology of immune-mediated tissue lesions including gastrointestinal, skin, rheumatic, pulmonary, cardiac, renal and hepatic lesions and highlight key immunological insights.
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Affiliation(s)
- Hajir Ibraheim
- Division of Digestive Diseases, Faculty of Medicine, Imperial College London, UK
- Gastroenterology Unit, Royal Marsden Hospital, London, UK
| | - Esperanza Perucha
- Centre for Inflammation Biology and Cancer Immunology, Centre for Rheumatic Diseases, King’s College London
| | - Nick Powell
- Division of Digestive Diseases, Faculty of Medicine, Imperial College London, UK
- Gastroenterology Unit, Royal Marsden Hospital, London, UK
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84
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Fessas P, Possamai LA, Clark J, Daniels E, Gudd C, Mullish BH, Alexander JL, Pinato DJ. Immunotoxicity from checkpoint inhibitor therapy: clinical features and underlying mechanisms. Immunology 2019; 159:167-177. [PMID: 31646612 DOI: 10.1111/imm.13141] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
Immune checkpoint inhibition with monoclonal antibodies is becoming increasingly commonplace in cancer medicine, having contributed to a widening of therapeutic options across oncological indications. Disruption of immune tolerance is the key mechanism of action of checkpoint inhibitors and although immune-related adverse events are a typical class effect of these compounds, the relationship between toxicity and response is not fully understood. Awareness and vigilance are paramount in recognizing potentially life-threatening toxicities and managing them in a timely manner. In this review article, we provide an overview of the clinical features, pathological findings and management principles of common immune-related toxicities, attempting to provide mechanistic insight into an increasingly common complication of cancer therapy.
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Affiliation(s)
- Petros Fessas
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Lucia A Possamai
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
| | - James Clark
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Ella Daniels
- National Centre for HIV Malignancy, Department of Oncology, Chelsea and Westminster Hospital, London, UK
| | - Cathrin Gudd
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
| | - Benjamin H Mullish
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
| | - James L Alexander
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
| | - David J Pinato
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK
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Vozy A, De Martin E, Johnson DB, Lebrun-Vignes B, Moslehi JJ, Salem JE. Increased reporting of fatal hepatitis associated with immune checkpoint inhibitors. Eur J Cancer 2019; 123:112-115. [PMID: 31678768 DOI: 10.1016/j.ejca.2019.09.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/24/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Aurore Vozy
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Centre, Pitié-Salpêtrière Hospital, Department of Pharmacology, UNICO-GRECO APHP.Sorbonne Cardio-oncology program, F-75013 Paris, France; Sorbonne Université, IUC APHP.6, Pitié-Salpêtrière Hospital, Department of Medical Oncology, F-75013 Paris, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Unité Inserm-Paris Sud 1193, Univ Paris-Sud, Université Paris-Saclay, DHU Hépatinov, Villejuif, F-94800, France
| | - Douglas B Johnson
- Departments of Medicine and Oncology, Cardio-oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bénédicte Lebrun-Vignes
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Centre, Pitié-Salpêtrière Hospital, Department of Pharmacology, UNICO-GRECO APHP.Sorbonne Cardio-oncology program, F-75013 Paris, France
| | - Javid J Moslehi
- Departments of Medicine and Oncology, Cardio-oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joe-Elie Salem
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Centre, Pitié-Salpêtrière Hospital, Department of Pharmacology, UNICO-GRECO APHP.Sorbonne Cardio-oncology program, F-75013 Paris, France; Departments of Medicine and Oncology, Cardio-oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA.
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Cheung V, Gupta T, Payne M, Middleton MR, Collier JD, Simmons A, Klenerman P, Brain O, Cobbold JF. Immunotherapy-related hepatitis: real-world experience from a tertiary centre. Frontline Gastroenterol 2019; 10:364-371. [PMID: 31656561 PMCID: PMC6788136 DOI: 10.1136/flgastro-2018-101146] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/04/2019] [Accepted: 02/24/2019] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Immune checkpoint inhibitors like anti-programmed cell death protein 1 (PD-1) drugs Nivolumab and Pembrolizumab and anti-cytotoxic T-lymphocyte associated (CTLA-4) drug Ipilimumab have become standard of care in many metastatic cancers. Immunotherapy-related hepatitis and cholangitis present a diagnostic and management challenge, being rare and incompletely characterised. We aim to report the incidence, features and treatments used for this in a real-world setting and to identify useful biomarkers, which can be used to predict effective use of steroids. DESIGN Retrospective review of 453 patients started on immunotherapy over 7 years. SETTING Tertiary hepatology and oncology centre. PATIENTS 21 patients identified with immunotherapy-related hepatotoxicity. RESULTS Hepatitis was most common in those receiving dual therapy (incidence 20%), with 75% of Grade 4 hepatitis cases occurring with ipilimumab-containing regimens. Corticosteroid monotherapy is first line treatment, but doses above 60 mg OD prednisolone do not demonstrate any additional benefit in time to hepatitis resolution. The alanine transaminase (ALT) reduction in steroid-responsive hepatitis is typically rapid (with a halving of ALT within 11 days). The commencement of additional immunosuppression (typically mycophenolate) appears safe and prompts a more rapid fall in ALT than corticosteroid use alone. Infliximab was safely used twice as hepatitis treatment. We also describe one patient with rare immunotherapy-induced biliary disease. CONCLUSIONS Vigilance is required for detection of immunotherapy-associated liver disease as, other than dual immunotherapy, we can identify no predictive factors for its development. Our data suggest that corticosteroid response is not dependent on the higher dosing regimens. Early escalation of immunosuppression may be of benefit in the absence of a rapid response to corticosteroids.
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Affiliation(s)
- Vincent Cheung
- Gastroenterology, Translational Gastroenterology Unit and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Tarun Gupta
- Gastroenterology, Translational Gastroenterology Unit and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | | | | | - Jane D Collier
- Hepatology, Translational Gastroenterology Unit and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Alison Simmons
- Gastroenterology, Translational Gastroenterology Unit and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Paul Klenerman
- Gastroenterology, Translational Gastroenterology Unit and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Oliver Brain
- Gastroenterology, Translational Gastroenterology Unit and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Jeremy F Cobbold
- Hepatology, Translational Gastroenterology Unit and NIHR Oxford Biomedical Research Centre, Oxford, UK
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87
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Izumi H, Kodani M, Kurai J, Takeda K, Okazaki R, Yamane K, Teruya Y, Yamamoto A, Sueda Y, Yanai M, Tanaka N, Sakamoto T, Yamaguchi K, Makino H, Igishi T, Yamasaki A. Nivolumab-induced cholangitis in patients with non-small cell lung cancer: Case series and a review of literature. Mol Clin Oncol 2019; 11:439-446. [PMID: 31616560 PMCID: PMC6781813 DOI: 10.3892/mco.2019.1923] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/21/2019] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs), including nivolumab, have exhibited substantial benefits in the treatment of several types of cancers. However, treatment with ICIs is often accompanied by immune-related adverse events (irAEs), and a clear understanding of the precise indications and management of irAEs is important for harnessing the full potential of these agents. While skin- or gastrointestinal-associated irAEs have been relatively well studied, there are few reports regarding nivolumab-induced cholangitis. We retrospectively reviewed data from patients with advanced or recurrent non-small cell lung cancer who were treated with nivolumab between December 2015 and December 2018 at Tottori University in Japan. Among the 59 patients, we identified four patients who experienced nivolumab-induced cholangitis. Of these four patients, stable disease (SD) was observed in two patients (50%), while partial response (PR) was achieved in two patients (50%) under nivolumab treatment. Patients were treated with corticosteroid alone (n=2) or in combination with mycophenolate mofetil (MMF) (n=2); these treatments resulted in improvements in nivolumab-induced cholangitis in three patients. In conclusion, the present retrospective study identified four cases of nivolumab-induced cholangitis. The combination of corticosteroid and MMF was effective in two cases with grade 4 nivolumab-induced cholangitis. Further reports are needed to establish the optimal management of patients with this irAE.
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Affiliation(s)
- Hiroki Izumi
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Masahiro Kodani
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Jun Kurai
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Kenichi Takeda
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Ryota Okazaki
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Kohei Yamane
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Yasuhiko Teruya
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Akihiro Yamamoto
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Yuriko Sueda
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Masaaki Yanai
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Natsumi Tanaka
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Tomohiro Sakamoto
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Kosuke Yamaguchi
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Haruhiko Makino
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Tadashi Igishi
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
| | - Akira Yamasaki
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan
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88
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Parakh S, King D, Gan HK, Scott AM. Current Development of Monoclonal Antibodies in Cancer Therapy. Recent Results Cancer Res 2019; 214:1-70. [PMID: 31473848 DOI: 10.1007/978-3-030-23765-3_1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Exploiting the unique specificity of monoclonal antibodies has revolutionized the treatment and diagnosis of haematological and solid organ malignancies; bringing benefit to millions of patients over the past decades. Recent achievements include conjugating antibodies with toxic payloads resulting in superior efficacy and/or reduced toxicity, development of molecular imaging techniques targeting specific antigens for use as predictive and prognostic biomarkers, the development of novel bi- and tri-specific antibodies to enhance therapeutic benefit and abrogate resistance and the success of immunotherapy agents. In this chapter, we review an overview of antibody structure and function relevant to cancer therapy and provide an overview of pivotal clinical trials which have led to regulatory approval of monoclonal antibodies in cancer treatment. We further discuss resistance mechanisms and the unique side effects of each class of antibody and provide an overview of emerging therapeutic agents.
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Affiliation(s)
- Sagun Parakh
- Tumour Targeting Laboratory, Olivia Newton-John Cancer Research Institute, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.,Department of Medical Oncology, Olivia Newton-John Cancer and Wellness Centre, Austin Health, Heidelberg, Melbourne, Australia.,School of Cancer Medicine, La Trobe University, Melbourne, Australia
| | - Dylan King
- Tumour Targeting Laboratory, Olivia Newton-John Cancer Research Institute, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.,School of Cancer Medicine, La Trobe University, Melbourne, Australia
| | - Hui K Gan
- Tumour Targeting Laboratory, Olivia Newton-John Cancer Research Institute, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.,Department of Medical Oncology, Olivia Newton-John Cancer and Wellness Centre, Austin Health, Heidelberg, Melbourne, Australia.,School of Cancer Medicine, La Trobe University, Melbourne, Australia
| | - Andrew M Scott
- Tumour Targeting Laboratory, Olivia Newton-John Cancer Research Institute, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia. .,School of Cancer Medicine, La Trobe University, Melbourne, Australia. .,Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Australia. .,Department of Medicine, University of Melbourne, Melbourne, Australia.
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89
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Wei H, Jiang H, Song B. Role of medical imaging for immune checkpoint blockade therapy: From response assessment to prognosis prediction. Cancer Med 2019; 8:5399-5413. [PMID: 31385454 PMCID: PMC6745848 DOI: 10.1002/cam4.2464] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/29/2019] [Accepted: 07/15/2019] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint blockade (ICB) represents a promising approach in cancer therapy. Owing to the peculiar biologic mechanisms of anticancer activity, checkpoint blockers are accompanied with distinctive response patterns and toxicity profiles. Medical imaging is the cornerstone for response assessment to immunotherapy and plays a critical role in monitoring of immune-related adverse events (irAEs). Imaging-based biomarkers have shown tremendous potential for the prediction of therapeutic efficacies and clinical outcomes in patients treated with checkpoint inhibitors. In this article, the landscape of current response assessment systems for immunotherapy was reviewed with a special focus on the latest advances in the assessment of responses to ICB. Emerging imaging biomarkers were discussed along with the challenges regarding their clinical transformation. In addition, the biological mechanisms and clinical applications of ICB and irAEs were also within the scope of this review.
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Affiliation(s)
- Hong Wei
- Department of RadiologySichuan University West China HospitalChengduSichuan ProvinceChina
| | - Hanyu Jiang
- Department of RadiologySichuan University West China HospitalChengduSichuan ProvinceChina
| | - Bin Song
- Department of RadiologySichuan University West China HospitalChengduSichuan ProvinceChina
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90
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Czaja AJ. Immune inhibitory proteins and their pathogenic and therapeutic implications in autoimmunity and autoimmune hepatitis. Autoimmunity 2019; 52:144-160. [PMID: 31298041 DOI: 10.1080/08916934.2019.1641200] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Key inhibitory proteins can blunt immune responses to self-antigens, and deficiencies in this repertoire may promote autoimmunity. The goals of this review are to describe the key immune inhibitory proteins, indicate their possible impact on the development of autoimmune disease, especially autoimmune hepatitis, and encourage studies to clarify their pathogenic role and candidacy as therapeutic targets. English abstracts were identified in PubMed by multiple search terms. Full length articles were selected for review, and secondary and tertiary bibliographies were developed. Cytotoxic T lymphocyte antigen-4 impairs ligation of CD28 to B7 ligands on antigen presenting cells and inhibits the adaptive immune response by increasing anti-inflammatory cytokines, generating regulatory T cells, and reducing T cell activation and proliferation. Programed cell death antigen-1 inhibits T cell selection, activation, and proliferation by binding with two ligands at different phases and locations of the immune response. A soluble alternatively spliced variant of this protein can dampen the inhibitory signal. Autoimmune hepatitis has been associated with polymorphisms of the cytotoxic T lymphocyte antigen-4 gene, reduced hepatic expression of a ligand of programed cell death antigen-1, an interfering soluble variant of this key inhibitory protein, and antibodies against it. Findings have been associated with laboratory indices of liver injury and suboptimal treatment response. Abatacept, belatacept, CD28 blockade, and induction of T cell exhaustion are management considerations that require scrutiny. In conclusion, deficiencies in key immune inhibitory proteins may promote the occurrence of autoimmune diseases, such as autoimmune hepatitis, and emerging interventions may overcome these deficiencies. Investigations should define the nature, impact and management of these inhibitory disturbances in autoimmune hepatitis.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
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91
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Hepatotoxicity After Immune Checkpoint Inhibitor Therapy in Melanoma: Natural Progression and Management. Am J Clin Oncol 2019; 41:760-765. [PMID: 28749795 DOI: 10.1097/coc.0000000000000374] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To report the clinical features, treatment, and outcomes of patients with immune checkpoint inhibitor-induced hepatotoxicity. PATIENTS AND METHODS In this retrospective observational study, we identified patients with metastatic malignant melanoma seen in consultation and/or treated between March 2011 and March 2016. Hepatotoxicity was assessed using the Common Terminology Criteria for Adverse Events, v4.0. RESULTS Seventeen patients were identified as having any degree of hepatotoxicity by history (grade 1 to 4). Twelve of 17 were diagnosed after ipilimumab, 3 of 17 were diagnosed after pembrolizumab, and 2 of 17 after ipilimumab combined with nivolumab. Median time from first dose of immune therapy to hepatotoxicity was 52 days. Clinical symptoms were variable: asymptomatic, fatigue, myalgias, headache, abdominal pain, nausea, vomiting, confusion, and/or jaundice. Eight patients had concurrent adverse events including colitis, hypophysitis, pneumonitis, and/or rash. Immune therapy was discontinued in all patients except 3. The patients were most commonly treated with systemic corticosteroids such as prednisone. Immunosuppression was discontinued by taper over a median of 42 days; in 3 patients steroids had to be reinitiated based on clinical or laboratory worsening of liver tests. Normalization of liver tests was seen within a median of 31 days of immunosuppression initiation. One patient with grade 4 hepatotoxicity had normalization with the addition of cyclosporine. CONCLUSIONS Melanoma patients treated with immune checkpoint inhibitors should be monitored regularly for hepatotoxicity. Treatment with discontinuation of therapy and initiation of corticosteroids is indicated with grade 3 or 4 hepatotoxicity. Cyclosporine may be beneficial in steroid-refractory hepatotoxicity.
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92
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Marin-Acevedo JA, Chirila RM, Dronca RS. Immune Checkpoint Inhibitor Toxicities. Mayo Clin Proc 2019; 94:1321-1329. [PMID: 31272574 DOI: 10.1016/j.mayocp.2019.03.012] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/01/2019] [Accepted: 03/13/2019] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibitors are molecules that increase the endogenous immune response against tumors. They have revolutionized the field of oncology. Since their initial approval for the treatment of advanced melanoma, their use has expanded to the treatment of several other advanced cancers. Unfortunately, immune checkpoint inhibitors have also been associated with the emergence of a new subset of autoimmune-like toxicities, known as immune-related adverse events. These toxicities differ depending on the agent, malignancy, and individual susceptibilities. Although the skin and colon are most commonly involved, any organ may be affected, including the liver, lungs, kidneys, and heart. Most of these toxicities are diagnosed by excluding other secondary infectious or inflammatory causes. Corticosteroids are commonly used for treatment of moderate and severe immune-related adverse events, although additional immunosuppressive therapy may occasionally be required. The occurrence of immune-related toxicities may require discontinuation of immunotherapy, depending on the specific toxicity and its severity. In this article, we provide a focused review to familiarize practicing clinicians with this important topic given that the use of immune checkpoint inhibitors continues to increase.
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Affiliation(s)
| | - Razvan M Chirila
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Roxana S Dronca
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL.
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93
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An imaging-based review of systemic therapies and associated toxicities in metastatic pancreatic cancer as per the 2018 ASCO guidelines: what every radiologist should know. Abdom Radiol (NY) 2019; 44:2182-2195. [PMID: 30820626 DOI: 10.1007/s00261-019-01954-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide an overview of what radiologists should know about systemic agents utilized in the modern treatment of metastatic pancreatic cancer and their associated toxicities. RESULTS The clinical landscape of metastatic pancreatic cancer has significantly evolved in recent years, with the advent of new first- and second-line systemic therapies. As these systemic treatment options continue to expand, knowledge of their clinically relevant features is becoming critical for radiologists. While the issues of surgical resectability and tumor response evaluation of advanced stages of pancreatic cancer have been thoroughly discussed in the radiology literature, the diagnostic importance of systemic therapies has tended to be less well appreciated. In this review, we provide a primer for radiologists outlining the radiologically pertinent features of modern systemic therapies used in the treatment of metastatic pancreatic ductal adenocarcinoma. These systemic agents are discussed from the standpoint of the newly updated 2018 ( https://doi.org/10.1007/s00261-019-01954-z ) guidelines for the treatment of metastatic pancreatic cancer from the American Society of Clinical Oncology (ASCO). Understanding the radiology relevance of these modern therapeutic agents is critical, especially with regard to treatment response and toxicity assessment. CONCLUSION Knowledge of the modern systemic therapies utilized in the treatment of metastatic pancreatic cancer and their associated toxicity profiles is critical in diagnostic imaging interpretation.
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94
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Alessandrino F, Sahu S, Nishino M, Adeni AE, Tirumani SH, Shinagare AB, Awad MM. Frequency and imaging features of abdominal immune-related adverse events in metastatic lung cancer patients treated with PD-1 inhibitor. Abdom Radiol (NY) 2019; 44:1917-1927. [PMID: 30790009 DOI: 10.1007/s00261-019-01935-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate the frequency and imaging features of radiographically evident abdominal immune-related adverse events (irAEs) in patients with metastatic non-small-cell lung cancer (NSCLC) treated with PD-1 inhibitors. METHODS This retrospective study included 137 patients with metastatic NSCLC treated with PD-1 inhibitor nivolumab monotherapy (75 women; median age: 65 years), who had a baseline CT and at least one follow-up abdomen CT during therapy. Baseline and all follow-up abdominal CTs performed for monitoring of nivolumab therapy were reviewed to identify the organ-specific abdominal irAEs including colitis/enteritis, hepatitis, biliary toxicity, pancreatitis, nephritis, sarcoid-like reaction, and pancreatic and adrenal atrophy. Their frequency and imaging features were described. RESULTS Eighteen (13%) patients had radiologically identified abdominal irAEs (median 2.1 months after starting nivolumab; interquartile range 1.17-5.83 months); 16 patients developed enteritis/colitis (12 pancolitis, two segmental colitis, one enterocolitis, one enteritis), two hepatitis, one adrenalitis. One patient with hepatitis also developed colitis/enteritis. Radiographic abdominal irAE occurred after nivolumab therapy was discontinued in six patients before any subsequent therapy was started. IrAEs prompted nivolumab interruption and treatment with steroids in four patients (three colitis/enteritis, one hepatitis). Most common CT features of colitis/enteritis included mesenteric hyperemia (n = 15), bowel wall thickening (n = 13), mucosal hyperenhancement (n = 10), and fluid-filled colon (n = 9). CONCLUSION Abdominal irAEs were detected on CT in 13% of NSCLC patients treated with nivolumab, and colitis, in the pancolitis form, was the most common irAE. Given the expanding role of immunotherapy, radiologists should be aware of the frequency and imaging manifestations of abdominal irAEs and the impact on patient management.
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95
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Widmann G, Nguyen VA, Plaickner J, Jaschke W. [Adverse effects of immunotherapy : Clinical aspects, radiological and nuclear medicine results]. Radiologe 2019; 57:840-849. [PMID: 28733704 DOI: 10.1007/s00117-017-0285-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The increasing use of immunotherapy in oncology increases the need for radiologic evaluation of frequent and severe immune-related adverse events. OBJECTIVE Determination of the incidence and manifestation of radiologic and nuclear medicine findings of immune-related adverse events. MATERIAL AND METHODS Literature review of clinical and imaging findings of immune-related adverse events induced by the immune checkpoint inhibitors ipilimumab, nivolumab and pembrolizumab. Findings are illustrated with pictorial examples and contrasted to other relevant differential diagnoses. RESULTS The most frequent imaging manifestations are colitis, hepatitis, pancreatitis, hypophysitis, pneumonitis, arthritis and sarcoid-like lymphadenopathy. Severe to life-threatening complications may result from colitis, pneumonitis and hypophysitis. A clear differentiation from other autoimmune diseases and discrimination of immune-related and infectious pulmonary findings can be very difficult and need close multidisciplinary collaboration. CONCLUSION Knowledge of clinical and imaging findings of adverse events induced by immunotherapy is essential for timely and adequate therapeutic decisions. In addition to staging and follow-up imaging, identification and monitoring of immune-related adverse events adds to the radiologic responsibility in oncologic care.
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Affiliation(s)
- G Widmann
- Universitätsklinik für Radiologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich.
| | - V A Nguyen
- Universitätsklinik für Dermatologie, Venerologie und Allergologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - J Plaickner
- Universitätsklinik für Radiologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - W Jaschke
- Universitätsklinik für Radiologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
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Abstract
Checkpoint inhibitors (CI) have revolutionized the management of many cancers but can result in immune-related adverse events (IRAE). In this chapter, we review the clinical manifestations and management of the most common IRAE, plus less common IRAE, such as inflammatory arthritis, of particular interest to rheumatologists. We review the mechanism of action of CI, predictors of IRAE, and the impact of IRAE on cancer outcomes. The study of IRAE is in its infancy; there are very few prospective studies and virtually no treatment trials. Where possible, we have drawn estimates of IRAE incidence from meta-analyses of randomized controlled trials. Clinical descriptions are derived from case series and case reports. Readers are encouraged to refer to consensus guidelines for IRAE management published by the American Society of Clinical Oncology and the Society for Immunotherapy of Cancer.
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97
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Webb GJ, Hirschfield GM, Krawitt EL, Gershwin ME. Cellular and Molecular Mechanisms of Autoimmune Hepatitis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2019; 13:247-292. [PMID: 29140756 DOI: 10.1146/annurev-pathol-020117-043534] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Autoimmune hepatitis is an uncommon idiopathic syndrome of immune-mediated destruction of hepatocytes, typically associated with autoantibodies. The disease etiology is incompletely understood but includes a clear association with human leukocyte antigen (HLA) variants and other non-HLA gene variants, female sex, and the environment. Pathologically, there is a CD4+ T cell-rich lymphocytic inflammatory infiltrate with variable hepatocyte necrosis and subsequent hepatic fibrosis. Attempts to understand pathogenesis are informed by several monogenetic syndromes that may include autoimmune liver injury, by several drug and environmental agents that have been identified as triggers in a minority of cases, by human studies that point toward a central role for CD4+ effector and regulatory T cells, and by animal models of the disease. Nonspecific immunosuppression is the current standard therapy. Further understanding of the disease's cellular and molecular mechanisms may assist in the design of better-targeted therapies, aid the limitation of adverse effects from therapy, and inform individualized risk assessment and prognostication.
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Affiliation(s)
- G J Webb
- National Institute for Health Research Liver Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, United Kingdom; ,
| | - G M Hirschfield
- National Institute for Health Research Liver Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, United Kingdom; ,
| | - E L Krawitt
- Department of Medicine, University of Vermont, Burlington, Vermont 05405, USA; .,Department of Medicine, Dartmouth College, Hanover, New Hampshire 03755, USA
| | - M E Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, School of Medicine, University of California, Davis, California 95817, USA;
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98
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Marshall C, Rajdev MA, Somarouthu B, Ramaiya NH, Alessandrino F. Overview of systemic treatment in recurrent and advanced cervical cancer: a primer for radiologists. Abdom Radiol (NY) 2019; 44:1506-1519. [PMID: 30288585 DOI: 10.1007/s00261-018-1797-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Imaging has a central role in surveillance of cervical cancer, guiding decision on when to initiate treatment for recurrent disease and to guide management in advanced cervical cancer. Due to the increased availability of pelvic radiation therapy, the rate of atypical presentation of recurrent disease has increased. Simultaneously, the array of systemic therapies now available for advanced cervical cancer has considerably expanded in the last few years, with therapies now available in mid and low-income countries. While pelvic recurrences are amenable of loco-regional treatment, recurrent disease may present with metastases to the thoracoabdominal organs, lymph nodes, bones, skin and brain, for which systemic treatment represent the standard of care. Besides combined chemotherapy regimens, alternative chemotherapies, biosimilars and immune checkpoint inhibitors are now available, each associated with a definite pattern of response and toxicity. In this review, after describing the typical and atypical presentations of recurrent and advanced cervical carcinoma on cross-sectional imaging, we will discuss systemic treatment for recurrent or advanced disease and their associated radiographic sequelae, in light of the newly available therapies.
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99
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Abstract
Immune checkpoint inhibitors, particularly those targeting PD-1/PD-L1, produce durable responses in a subset of patients across cancer types. Although often well tolerated, these agents can induce a broad spectrum of autoimmune-like complications that may affect any organ system. Treatment of these toxicities primarily consists of immune suppression with corticosteroids and other agents. This review briefly discusses the mechanisms of immune-related adverse events, overviews the clinical and pathologic features of major toxicities caused by PD-1/PD-L1 blockade, and reviews their management.
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Affiliation(s)
- Daniel Y Wang
- From the Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN
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100
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Zhang HC, Luo W, Wang Y. Acute liver injury in the context of immune checkpoint inhibitor-related colitis treated with infliximab. J Immunother Cancer 2019; 7:47. [PMID: 30777137 PMCID: PMC6380028 DOI: 10.1186/s40425-019-0532-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 02/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Immune checkpoint inhibitors (ICPIs), used to treat different advanced malignancies, are associated with a wide range of immune-related adverse reactions (irAEs) that deserve close monitoring of patients. Gastrointestinal reactions and hepatotoxicity may occur, which warrant careful evaluation to confirm the etiology and attribution to ICPIs as these events could affect future management. Case presentation We describe a case of a patient with prostate adenocarcinoma, treated with dual ICPIs comprised of ipilimumab and nivolumab, who developed elevated liver enzymes in the context of infliximab therapy prescribed to treat gastrointestinal irAE from his ICPIs. The patient’s grade 3 colitis became steroid-refractory, requiring a one-time infusion of infliximab, a biologic agent used commonly in inflammatory bowel disease, as a rescue therapy, to which he responded. The patient subsequently developed liver injury. This presented a diagnostic dilemma involving differential diagnoses of hepatotoxicity due to ICPI or infliximab exposure. A careful review of the clinical history, evaluation of the chronology of events, and exclusion of other causes of acute hepatitis were employed to make the final diagnosis of this event as infliximab-associated hepatotoxicity. Conclusion ICPIs such as CTLA-4 and PD-1 inhibitors have the potential to cause both gastrointestinal reactions and hepatotoxicity. An additional confounding factor in our patient’s case was the exposure to infliximab used to manage an established irAE that developed after the last exposure to ICPIs. The clinical history and data supported infliximab-associated hepatotoxicity, rather than an irAE. With the increasing application of ICPIs for different cancers, in conjunction with potential risks for irAE, the liver profile should be closely monitored during treatment with ICPI as well as with anti-TNF-α agents in this patient population.
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Affiliation(s)
- Hao Chi Zhang
- Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Wenyi Luo
- Department of Pathology/Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA.
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