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Poto R, Troiani T, Criscuolo G, Marone G, Ciardiello F, Tocchetti CG, Varricchi G. Holistic Approach to Immune Checkpoint Inhibitor-Related Adverse Events. Front Immunol 2022; 13:804597. [PMID: 35432346 PMCID: PMC9005797 DOI: 10.3389/fimmu.2022.804597] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) block inhibitory molecules, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), or its ligand, programmed cell death protein ligand 1 (PD-L1) and enhance antitumor T-cell activity. ICIs provide clinical benefits in a percentage of patients with advanced cancers, but they are usually associated with a remarkable spectrum of immune-related adverse events (irAEs) (e.g., rash, colitis, hepatitis, pneumonitis, endocrine, cardiac and musculoskeletal dysfunctions). Particularly patients on combination therapy (e.g., anti-CTLA-4 plus anti-PD-1/PD-L1) experience some form of irAEs. Different mechanisms have been postulated to explain these adverse events. Host factors such as genotype, gut microbiome and pre-existing autoimmune disorders may affect the risk of adverse events. Fatal ICI-related irAEs are due to myocarditis, colitis or pneumonitis. irAEs usually occur within the first months after ICI initiation but can develop as early as after the first dose to years after ICI initiation. Most irAEs resolve pharmacologically, but some appear to be persistent. Glucocorticoids represent the mainstay of management of irAEs, but other immunosuppressive drugs can be used to mitigate refractory irAEs. In the absence of specific trials, several guidelines, based on data from retrospective studies and expert consensus, have been published to guide the management of ICI-related irAEs.
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Affiliation(s)
- Remo Poto
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Teresa Troiani
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gjada Criscuolo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | | | - Fortunato Ciardiello
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
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Siu DHW, O'Neill RS, Harris CA, Wang J, Ardolino L, Downton T, Tong M, Hong JH, Chin V, Clingan PR, Aghmesheh M, Soudy H. Immune checkpoint inhibitor-induced myocarditis, myositis, myasthenia gravis and transaminitis: a case series and review. Immunotherapy 2022; 14:511-520. [PMID: 35321560 DOI: 10.2217/imt-2021-0225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors have been incorporated into the treatment of various malignancies. An increasing body of literature is reporting rare but potentially fatal adverse events associated with these agents. In this case series, the authors report the clinical features and outcomes of seven patients who received immune checkpoint inhibitors for different solid organ malignancies and developed a tetrad of immune-related myocarditis, myositis, myasthenia gravis and transaminitis. Herein the authors review the literature and describe the current diagnostic and management approach for this overlapping syndrome. The authors' series highlights the importance of a high index of clinical suspicion, prompt comprehensive investigations, early multidisciplinary team involvement and initiation of immunosuppressive therapy when immune-related adverse events are suspected.
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Affiliation(s)
- Derrick Ho Wai Siu
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, 2050, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia
| | - Robert Sean O'Neill
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Carole A Harris
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Justine Wang
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Neurology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia
| | - Luke Ardolino
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, The Kinghorn Centre, St Vincent's Hospital, Darlinghurst, New South Wales, 2010, Australia
| | - Teesha Downton
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia
| | - Matthew Tong
- Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Jun Hee Hong
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia
| | - Venessa Chin
- Department of Medical Oncology, The Kinghorn Centre, St Vincent's Hospital, Darlinghurst, New South Wales, 2010, Australia.,Single Cell and Computational Genomics Lab, The Garvan Institute of Medical Research, Darlinghurst, New South Wales, 2010, Australia
| | - Philip R Clingan
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia.,University of Wollongong, New South Wales, Australia
| | - Morteza Aghmesheh
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia.,University of Wollongong, New South Wales, Australia
| | - Hussein Soudy
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
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Ammirati E, Bizzi E, Veronese G, Groh M, Van de Heyning CM, Lehtonen J, Pineton de Chambrun M, Cereda A, Picchi C, Trotta L, Moslehi JJ, Brucato A. Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis. Front Med (Lausanne) 2022; 9:838564. [PMID: 35350578 PMCID: PMC8958011 DOI: 10.3389/fmed.2022.838564] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
The field of inflammatory disease of the heart or "cardio-immunology" is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.
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Affiliation(s)
- Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy
| | - Emanuele Bizzi
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Giacomo Veronese
- Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Matthieu Groh
- National Reference Center for Hypereosinophilic Syndromes, CEREO, Suresnes, France
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Caroline M. Van de Heyning
- Department of Cardiology, Antwerp University Hospital, and GENCOR Research Group, Antwerp University, Antwerp, Belgium
| | - Jukka Lehtonen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
- Sorbonne Université, APHP, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence National Lupus et SAPL et Autres Maladies Auto-immunes et Systémiques Rares, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, ICAN, Paris, France
| | - Alberto Cereda
- Cardiovascular Department, Association Socio Sanitary Territorial Santi Paolo e Carlo, Milano, Italy
| | - Chiara Picchi
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Lucia Trotta
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Javid J. Moslehi
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco, ” Fatebenefratelli Hospital, University of Milano, Milano, Italy
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Cunningham-Bussel A, Wang J, Prisco LC, Martin LW, Vanni KM, Zaccardelli A, Nasrallah M, Gedmintas L, MacFarlane LA, Shadick NA, Awad MM, Rahma O, LeBoeuf NR, Gravallese EM, Sparks JA. Predictors of Rheumatic Immune-Related Adverse Events and De Novo Inflammatory Arthritis After Immune Checkpoint Inhibitor Treatment for Cancer. Arthritis Rheumatol 2022; 74:527-540. [PMID: 34397169 PMCID: PMC8847547 DOI: 10.1002/art.41949] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/29/2021] [Accepted: 08/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To identify predictors of rheumatic immune-related adverse events (irAEs) following immune checkpoint inhibitor (ICI) treatment for cancer. METHODS We performed a case-control study to predict the occurrence of rheumatic irAEs in cancer patients who initiated ICI treatment at Mass General Brigham and the Dana-Farber Cancer Institute between 2011 and 2020. We screened for the presence of rheumatic irAEs by reviewing the medical records of patients evaluated by rheumatologists or those prescribed nonglucocorticoid immunomodulatory drugs after the time of ICI initiation (baseline). Review of medical records confirmed the presence of rheumatic irAEs and the indications necessitating immunomodulatory drug treatment. Controls were defined as patients who did not experience rheumatic irAEs, did not have preexisting rheumatic disease, did not have a clinical evaluation by a rheumatologist after ICI treatment, did not receive an immunomodulatory drug after ICI, did not receive systemic glucocorticoids after ICI, and survived at least 6 months after the initial ICI treatment. We used logistic regression to estimate the odds ratios (ORs) (with 95% confidence intervals [95% CIs]) for the risk of a rheumatic irAE in the presence of various baseline predictors. RESULTS A total of 8,028 ICI recipients were identified (mean age 65.5 years, 43.1% female, 31.8% with lung cancer). After ICI initiation, 404 patients (5.0%) were evaluated by rheumatologists, and 475 patients (5.9%) received an immunomodulatory drug to treat any irAEs. There were 226 confirmed rheumatic irAE cases (2.8%) and 118 de novo inflammatory arthritis cases (1.5%). Rheumatic diseases (either preexisting rheumatic diseases or rheumatic irAEs) were a common indication for immunomodulatory drug use (27.9%). Baseline predictors of rheumatic irAEs included melanoma (multivariable OR 4.06 [95% CI 2.54-6.51]) and genitourinary (GU) cancer (OR 2.22 [95% CI 1.39-3.54]), both relative to patients with lung cancer; combination ICI treatment (OR 2.35 [95% CI 1.48-3.74]), relative to patients receiving programmed death 1 inhibitor monotherapy; autoimmune disease (OR 2.04 [95% CI 1.45-2.85]) and recent glucocorticoid use (OR 2.13 [95% CI 1.51-2.98]), relative to patients not receiving a glucocorticoid, compared to the 2,312 controls without rheumatic irAEs. Predictors of de novo inflammatory arthritis were similar to those of rheumatic irAEs. CONCLUSION We identified novel predictors of rheumatic irAE development in cancer patients, including baseline presence of melanoma, baseline presence of GU tract cancer, preexisting autoimmune disease, receiving or having received combination ICI treatment, and receiving or having received glucocorticoids. The proportion of cancer patients experiencing rheumatic irAEs may be even higher than was reported in the present study, since we used stringent criteria to identify cases of rheumatic irAEs. Our findings could be used to identify cancer patients at risk of developing rheumatic irAEs and de novo inflammatory arthritis and may help further elucidate the pathogenesis of rheumatic irAEs in patients with cancer who are receiving ICI treatment.
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Affiliation(s)
- Amy Cunningham-Bussel
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jiaqi Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lauren C. Prisco
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lily W. Martin
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kathleen M.M. Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alessandra Zaccardelli
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mazen Nasrallah
- Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Lydia Gedmintas
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Lindsey A. MacFarlane
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nancy A. Shadick
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mark M. Awad
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Osama Rahma
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nicole R. LeBoeuf
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Dermatology, Brigham and Women’s Hospital
| | - Ellen M. Gravallese
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeffrey A. Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Hypersensitivity Reactions and Immune-Related Adverse Events to Immune Checkpoint Inhibitors: Approaches, Mechanisms, and Models. Immunol Allergy Clin North Am 2022; 42:285-305. [DOI: 10.1016/j.iac.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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56
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Shindo A, Yamasaki M, Uchino K, Yamasaki M. Asymptomatic Myocarditis with Mild Cardiac Marker Elevation Following Nivolumab-Induced Myositis. Int Heart J 2022; 63:180-183. [DOI: 10.1536/ihj.21-653] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Akito Shindo
- Department of Cardiology, NTT Medical Center Tokyo
| | | | - Keita Uchino
- Department of Medical Oncology, NTT Medical Center Tokyo
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Kawataki M, Nakanishi Y, Yokoyama T, Ishida T. Hypothyroidism as an immune-related adverse event caused by atezolizumab in a patient with muscle spasms: a case report. Respir Med Case Rep 2022; 36:101585. [PMID: 35116222 PMCID: PMC8792264 DOI: 10.1016/j.rmcr.2022.101585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/12/2022] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
A 60-year-old man with a history of 4 cycles of atezolizumab treatment for non-small cell lung cancer presented to our hospital with a chief complaint of proximal muscle-dominant spasms. Blood tests showed elevated creatine phosphokinase (CPK) of 8450 U/L and hypothyroidism. There was little improvement even after stopping levetiracetam and pregabalin, and no subspinous physical findings of myositis. After levothyroxine was started for hypothyroidism, his muscle cramps and serum CPK level improved. Hypothyroidism as an immune-related adverse event can cause muscle spasms and is important in the differential diagnosis of muscle spasms in patients treated with immune checkpoint inhibitors.
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58
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Strobel SB, Machiraju D, Kälber KA, Hassel JC. Immune-related adverse events of COVID-19 vaccination in skin cancer patients receiving immune-checkpoint inhibitor treatment. Cancer Immunol Immunother 2021; 71:2051-2056. [PMID: 34940894 PMCID: PMC8695667 DOI: 10.1007/s00262-021-03133-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022]
Abstract
To date, few data are available regarding Adverse events (AEs) in cancer patients who are vaccinated for coronavirus disease 2019 (COVID-19) while being actively treated with Immune-checkpoint inhibitors (ICIs). We aimed to assess the safety of COVID-19 vaccines approved in Germany. Specifically, we investigated the frequency of general side effects and immune-related AEs of COVID-19 vaccination. A triage survey was used to collect the following information for patients with metastatic skin cancer: vaccine type, date of receipt of each dose of vaccine, and self-reported side effects. Clinical data were retrieved from the patients’ medical records. Of 130 patients with metastatic skin cancer, 89 patients were on immunotherapy and received COVID-19 vaccination. Of these 89 patients (median age: 64 years; 57 [64%] men), 89% had melanoma, and 71% received ICI therapy with a PD-1 antibody. Eighty-eight percent received an mRNA-based COVID-19 vaccination. The median follow-up time was 125 days after the first vaccination, and 84 days after the second. The most common observed side effects were mild to moderate pain at the injection site (40%), followed by fatigue (24%). Grade 3 irAEs were reported in eight patients, seven of whom were on nivolumab plus ipilimumab combination treatment. Of the 19 patients vaccinated within 72 h before/after ICI, five developed irAEs within 17 days (1–17 days). This small cohort study suggests that approved COVID-19 vaccinations are safe for use in cancer patients receiving ICIs. However, some precautions should be taken, especially regarding the timing of vaccination and ICI treatment.
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Affiliation(s)
- Sophia B Strobel
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
| | - Devayani Machiraju
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Katharina A Kälber
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
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Sun JY, Qu Q, Lou YX, Hua Y, Sun GZ, Sun W, Kong XQ. Cardiotoxicity in cancer immune-checkpoint therapy: Mechanisms, clinical evidence, and management strategies. Int J Cardiol 2021; 344:170-178. [PMID: 34563597 DOI: 10.1016/j.ijcard.2021.09.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 12/17/2022]
Abstract
Immune-checkpoint inhibitors (ICIs), a unique antibody-based therapeutic strategy, have revolutionized the treatment landscape of solid and hematological cancers. Despite the proven benefits of ICIs, the cardiotoxicity from unspecific immune activation (uncommon but potentially fatal) is a continuing concern. Accumulating preclinical research has demonstrated that ICIs initiate inflammation in the myocardium, while clinically significant cardiotoxicity were reported in few patients receiving ICI therapy, probably due to the low incidence and unspecific symptoms. The subtle signs and symptoms (e.g., chest pain, dizziness, and dyspnea) were likely attributed to cancer and/or non-cardiac events by previous studies, thus limiting the understanding of the incidence, outcomes, risk factors, and management of ICI-related cardiotoxicity. The heterogeneous clinical presentation and complex diagnostic procedure further make it challenging to accurately identify ICI-related cardiac events in clinical trials. Therefore, ICI-related cardiotoxicity, whose incidence is probably underestimated, has not been well recognized. In this article, we provide an overview of potential mechanisms underlying ICI-related cardiotoxicity and review accumulating clinical evidence of ICI-related cardiotoxicity, with a focus on myocarditis. Moreover, we discuss possible strategies to manage ICI-related cardiotoxicity and highlight the importance of developing cardio-oncology.
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Affiliation(s)
- Jin-Yu Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Qiang Qu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yu-Xuan Lou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yang Hua
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Guo-Zhen Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Wei Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China..
| | - Xiang-Qing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China..
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How we identify and treat neuromuscular toxicity induced by immune checkpoint inhibitors. ESMO Open 2021; 6:100317. [PMID: 34839103 PMCID: PMC8637479 DOI: 10.1016/j.esmoop.2021.100317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 12/17/2022] Open
Abstract
Immune-related neuromuscular adverse events are rare, but potentially life-threatening side-effects of immune checkpoint inhibitors (ICIs). They usually arise within the first 3 months after initiation of ICIs. Subacute symptom onset with more rapid progression than in idiopathic autoimmune neuromuscular diseases is typical. Prompt clinical diagnosis and treatment is essential for a favourable outcome. The importance of careful medical history and a well-established clinical diagnosis is emphasised rather than antibody detection or radiologic visualisation. Muscle weakness as a leading symptom can give rise to the suspicion of either neuropathy or myositis-myasthenia complex and differentiation may be complicated by their overlap. It is of utmost importance to recognise immune-related myositis and monitor for myocardial as well as bulbar involvement that may rapidly lead to cardiac or respiratory failure, persisting disability or even a fatal outcome. Symptoms typically improve with ICI discontinuation and early administration of glucocorticoids (prednisolone 1-2 mg/kg/day) in patients markedly affected. Severe and persisting symptoms including myocardial or bulbar affection can require therapy escalation to steroid-sparing agents. In patients with mild symptoms, not influencing functional abilities, careful clinical monitoring while staying on ICI therapy may be sufficient. Re-challenging with ICIs may be considered in selected cases, based on the initial severity of immune-related adverse events (irAEs) and clinical disease course. Depending on the individual irAE characteristics, the decision should be preferably discussed in an interdisciplinary irAE expert team with an experienced neurologist, rheumatologist and/or cardiologist and take the patient's preferences into account. The yet unmet need of systematic data on treatment, follow-up results and options of re-challenge of ICI treatment in neuromuscular toxicity has to be particularly considered in the shared decision-making process. Immune-related neuromuscular adverse events are rare, but potentially life-threatening side-effects of immunotherapy. Muscle weakness as the leading symptom can give rise to the suspicion of either neuropathy or myositis-myasthenia complex. Symptoms typically improve with ICI discontinuation and early administration of glucocorticoids. Severe persisting symptoms including myocardial or bulbar affection can require therapy escalation to steroid-sparing agents.
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Fan J, Feng Y, Tao Z, Chen J, Yang H, Shi Q, Li Z, She T, Li H, Jin Y, Cheng J, Lu X. A versatile platform for the tumor-targeted delivery of immune checkpoint-blocking immunoglobin G. J Control Release 2021; 340:243-258. [PMID: 34752799 DOI: 10.1016/j.jconrel.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 02/05/2023]
Abstract
Immunotherapies based on immune checkpoint-blocking antibodies have been considered the most attractive cancer treatments in recent years. However, the systemic administration of immune checkpoint-blocking antibodies is limited by low response rates and high risk of inducing immune-related adverse events (irAEs), which might be overcome by the tumor-targeted delivery of these antibodies. To achieve tumor-targeted delivery, immune checkpoint-blocking antibodies are usually modified with tumor-homing ligands through difficult genetic fusion or chemical conjugation. As most immune checkpoint-blocking antibodies are immunoglobin G (IgG) antibodies, we hypothesize that these IgG antibodies might be noncovalently modified with a tumor-homing ligand fused to an IgG-binding domain (IgBD). To test this hypothesis, the tumor-homing ZPDGFRβ affibody, which targets platelet-derived growth factor receptor β (PDGFRβ), was fused to the Fab-selective IgBD in a trimeric format. After mixing ZPDGFRβ fused to the IgBD with immune checkpoint-blocking IgG against programmed death-ligand 1 (αPD-L1), a novel homogenous complex was formed, indicating that αPD-L1 had been successfully modified with ZPDGFRβ fused to the IgBD. ZPDGFRβ-modified αPD-L1 bound to both PDGFRβ and PD-L1, thus leading to greater tumor uptake and antitumor effects in mice bearing PDGFRβ+PD-L1+ tumor grafts. In addition, due to the broad spectrum of IgBD for IgG, immune checkpoint-blocking IgG antibodies against cytotoxic T-lymphocyte-associated protein 4 (αCTLA-4) and signal regulatory protein alpha (αSIRPα) were also modified with ZPDGFRβ fused to the IgBD. These results demonstrated that a tumor-homing ligand fused to the IgBD might be developed as a versatile platform for the modification of immune checkpoint-blocking IgG antibodies to achieve tumor-targeted delivery.
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Affiliation(s)
- Jie Fan
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yanru Feng
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ze Tao
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China; Sichuan Provincial Engineering Laboratory of Pathology in Clinical Application, West China Hospital, Sichuan University, Chengdu 610041, China; Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jie Chen
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hao Yang
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China; Sichuan Provincial Engineering Laboratory of Pathology in Clinical Application, West China Hospital, Sichuan University, Chengdu 610041, China; Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Qiuxiao Shi
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Zhao Li
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Tianshan She
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Heng Li
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Youmei Jin
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jingqiu Cheng
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China; Sichuan Provincial Engineering Laboratory of Pathology in Clinical Application, West China Hospital, Sichuan University, Chengdu 610041, China; Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China.
| | - Xiaofeng Lu
- Key Lab of Transplant Engineering and Immunology, MOH, West China Hospital, Sichuan University, Chengdu 610041, China; Sichuan Provincial Engineering Laboratory of Pathology in Clinical Application, West China Hospital, Sichuan University, Chengdu 610041, China; Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China.
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Campochiaro C, Farina N, Tomelleri A, Ferrara R, Lazzari C, De Luca G, Bulotta A, Signorelli D, Palmisano A, Vignale D, Peretto G, Sala S, Esposito A, Garassino M, Gregorc V, Dagna L. Tocilizumab for the treatment of immune-related adverse events: a systematic literature review and a multicentre case series. Eur J Intern Med 2021; 93:87-94. [PMID: 34391591 DOI: 10.1016/j.ejim.2021.07.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Research is moving towards a more personalized management of immune-related adverse events (irAEs) due to immune checkpoint inhibitors (ICI). Our objective was to evaluate the efficacy and safety of tocilizumab in the treatment of these clinical manifestations. METHODS A systematic literature review was performed to retrieve data about the use of tocilizumab in the treatment of irAEs. Additionally, data from cancer patients referred to our Immune-related Adverse Event Clinic and treated with tocilizumab were collected. RESULTS Our literature review identified 20 articles and 11 meeting abstracts. Data about 91 cancer patients who received tocilizumab for the treatment of irAEs were collected. In 85% of cases, this therapy was associated with clinical benefit and no case of disease progression was reported. ICI therapy was continued following irAE onset and biologic therapy initiation in only three patients. Five patients developed irAEs upon ICI initiation and were subsequently treated with tocilizumab at our Centre. At a median follow-up of eight months, tocilizumab was safely continued along with ICI in three out of five patients, and an adequate control of irAE was obtained in all cases. No significant adverse reactions to tocilizumab were reported. Only one patient experienced a disease progression 18 months after ICI discontinuation. CONCLUSION Both our systematic literature review and case series highlight the efficacy and safety of tocilizumab in the treatment of irAEs. Furthermore, they both support the possibility of a combined approach with tocilizumab and ICI, to guarantee an effective irAEs management without losing the oncologic response.
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Affiliation(s)
- Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, via Olgettina 60, Milan, Italy.
| | - Nicola Farina
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, via Olgettina 60, Milan, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, via Olgettina 60, Milan, Italy
| | - Roberto Ferrara
- Thoracic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, via Venezian 1, Milan, Italy
| | - Chiara Lazzari
- Department of Oncology, IRCCS San Raffaele, via Olgettina 60, Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, via Olgettina 60, Milan, Italy
| | - Alessandra Bulotta
- Department of Oncology, IRCCS San Raffaele, via Olgettina 60, Milan, Italy
| | - Diego Signorelli
- Thoracic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, via Venezian 1, Milan, Italy
| | - Anna Palmisano
- Department of Radiology, IRCCS San Raffaele Hospital, via Olgettina 60, Milan, Italy
| | - Davide Vignale
- Department of Radiology, IRCCS San Raffaele Hospital, via Olgettina 60, Milan, Italy
| | - Giovanni Peretto
- Department of Arrhythmology, IRCCS San Raffaele Hospital, via Olgettina 60, Milan, Italy
| | - Simone Sala
- Department of Arrhythmology, IRCCS San Raffaele Hospital, via Olgettina 60, Milan, Italy
| | - Antonio Esposito
- Department of Radiology, IRCCS San Raffaele Hospital, via Olgettina 60, Milan, Italy
| | - Marina Garassino
- Thoracic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, via Venezian 1, Milan, Italy
| | - Vanesa Gregorc
- Department of Oncology, IRCCS San Raffaele, via Olgettina 60, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, via Olgettina 60, Milan, Italy
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63
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Hajem S, Ederhy S, Champiat S, Troalen F, Nolin-Lapalme A, Berhoune M, Cauquil C, Martin-Romano P, Baldini C, Laparra A, Vuagnat P, Hollebecque A, Mateus C, Besse B, Naltet C, Robert C, Marabelle A, Massard C, Lambotte O, Michot JM. Absence of significant clinical benefit for a systematic routine creatine phosphokinase measurement in asymptomatic patients treated with anti-programmed death protein (ligand) 1 immune checkpoint inhibitor to screen cardiac or neuromuscular immune-related toxicities. Eur J Cancer 2021; 157:383-390. [PMID: 34571335 DOI: 10.1016/j.ejca.2021.08.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 12/17/2022]
Abstract
AIM Despite unprecedented results of anti-programmed death protein (ligand) 1 (PD-(L)1) immune checkpoint inhibitor in the oncology's armamentarium, immune-related adverse events (irAEs) represent a therapeutic hurdle. Currently, there is no consensual recommendation on a routinely monitored biomarker to early detect irAE. Biological markers such as serum creatine phosphokinase (CPK) are commonly used to measure muscular tissue injury. The potential of routine serum CPK monitoring to predict cardiac or neuromuscular irAE in patients treated with immunotherapy remains unknown. METHODS In this retrospective study between January 2016 and December 2018 at Gustave Roussy Cancer Campus, 1151 cancer patients treated with anti-PD-(L)1 immunotherapy were systematically monitored with serum CPK measurements before each immunotherapy cycle. We considered significant CPK increases according to Common Terminology Criteria for Adverse Events v5.0 (CTCAEV5) of grade ≥2 severity. Comparisons were performed in patients with immune-related CPK (ir-CPK) elevations symptomatic versus asymptomatic. RESULTS Overall, 53 of 1151 (4.6%) patients showed a CPK increase. Elevations of CPK were deemed to be immunotherapy-related in 31 of 1151 (2.7%) patients. Among them, 12 of 31 (38.7%) patients experienced symptomatic cardiac or neuromuscular irAE, whereas the other 19 of 31 (61.3%) patients remained asymptomatic. In patients with symptomatic irAE, the mean ir-CPK level was higher compared with asymptomatic patients (1271 versus 771 UI/L, P value = 0.02). In the asymptomatic group, all patients experienced a spontaneous resolution of the ir-CPK increase, and none required medical intervention. CONCLUSION Most patients with immune-related CPK increase remained asymptomatic. The CPK serum increase did not alter the clinical management of asymptomatic patients. The results of this study did not support a significant clinical interest for a systematic routine CPK monitoring in patients amenable to anti-PD-(L)1 immunotherapy.
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Affiliation(s)
- Samia Hajem
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France; Centre de Recherche Du Centre Hospitalier de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
| | - Stéphane Ederhy
- Department of Cardiology, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, UNICO-GRECO Cardio-oncology Program, France
| | - Stéphane Champiat
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Frédéric Troalen
- Department of Biology, Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Alexis Nolin-Lapalme
- Centre de Recherche Du Centre Hospitalier de Montréal (CRCHUM), Université de Montréal, Montréal, Canada
| | - Malik Berhoune
- Department of Pharmacy, Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Cécile Cauquil
- Department of Neurology, Kremlin Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Patricia Martin-Romano
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Capucine Baldini
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Ariane Laparra
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Perrine Vuagnat
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Antoine Hollebecque
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Christine Mateus
- Department of Oncology, Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Benjamin Besse
- Department of Oncology, Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Charles Naltet
- Department of Oncology, Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Caroline Robert
- Department of Oncology, Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Aurélien Marabelle
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Christophe Massard
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France
| | - Olivier Lambotte
- Clinical Immunology Department, Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, 94270, Le Kremlin Bicêtre, France; Université Paris-Saclay, INSERM, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IDMIT/IMVA-HB), UMR1184, 94270, Le Kremlin Bicêtre, France
| | - Jean-Marie Michot
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Sud, Université Paris-Saclay, F-94805, Villejuif, France.
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Pathak R, Katel A, Massarelli E, Villaflor VM, Sun V, Salgia R. Immune Checkpoint Inhibitor-Induced Myocarditis with Myositis/Myasthenia Gravis Overlap Syndrome: A Systematic Review of Cases. Oncologist 2021; 26:1052-1061. [PMID: 34378270 DOI: 10.1002/onco.13931] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/30/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The development of immune checkpoint inhibitors (ICIs) represents a paradigm shift in the treatment of cancers. Despite showing remarkable efficacy, these agents can be associated with life-threatening immune-related adverse events. In recent years, several cases of myocarditis with myositis and/or myasthenia gravis overlap syndrome (IM3OS) have been reported. However, given the rarity, the clinical features and outcomes of these cases remain poorly understood. We, therefore, attempted to systematically review and summarize all cases of IM3OS reported in the literature. MATERIALS AND METHODS Studies reporting IM3OS were identified in Embase and MEDLINE. Only case reports and case series published in journals or presented at conferences were included. We conducted a systematic review according to the PRISMA Harms guidelines. RESULTS A total of 60 cases were eligible. The patients' median age was 71 years, and the majority (67%) were males; melanoma was the most common indication for ICIs (38%). The most-reported symptoms were fatigue (80%) and muscle weakness (78%). The median number of doses to the development of IM3OS was one. The average creatine kinase level was 9,645 IU/L. Cardiac arrhythmias occurred in 67% of patients, and 18% had depressed ejection fraction. Initial treatment consisted of immunosuppression with high-dose steroids and supportive therapies. Sixty percent of the patients died in hospital because of acute complications. CONCLUSION IM3OS can be associated with significant mortality and morbidity. Prospective studies are needed to understand the optimal approach to diagnose and manage these patients and to develop biomarkers to predict the occurrence and severity of this rare but serious condition. IMPLICATIONS FOR PRACTICE Clinicians should suspect coexisting myositis and/or myasthenia gravis in all patients with immune checkpoint inhibitor-induced myocarditis, given their propensity to occur together. Early recognition and prompt treatment with the help of a multidisciplinary team might help improve the outcomes of this life-threatening condition.
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Affiliation(s)
- Ranjan Pathak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Anjan Katel
- Department of Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Erminia Massarelli
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Victoria M Villaflor
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Virginia Sun
- Department of Population Science, City of Hope, Duarte, California, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
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65
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Lehmann LH, Cautela J, Palaskas N, Baik AH, Meijers WC, Allenbach Y, Alexandre J, Rassaf T, Müller OJ, Aras M, Asnani AH, Deswal A, Laufer-Perl M, Thuny F, Kerneis M, Hayek SS, Ederhy S, Salem JE, Moslehi JJ. Clinical Strategy for the Diagnosis and Treatment of Immune Checkpoint Inhibitor-Associated Myocarditis: A Narrative Review. JAMA Cardiol 2021; 6:1329-1337. [PMID: 34232253 DOI: 10.1001/jamacardio.2021.2241] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance In the last decade, immune checkpoint inhibitors (ICIs) have been approved for the treatment of many cancer types. Immune checkpoint inhibitor-associated myocarditis has emerged as a significant and potentially fatal adverse effect. Recognizing, diagnosing, and treating ICI-associated myocarditis poses new challenges for the practicing clinician. Here, the current literature on ICI-associated myocarditis is reviewed. Observations Clinical presentation and cardiac pathological findings are highly variable in patients with ICI-associated myocarditis. Although endomyocardial biopsy is the criterion standard diagnostic test, a combination of clinical suspicion, cardiac biomarkers (specifically troponin), and cardiac imaging, in addition to biopsy, is often needed to support the diagnosis. Importantly, the combination of a cytotoxic T-lymphocyte-associated protein 4 inhibitor with a programmed cell death protein 1 or programmed death-ligand 1 inhibitor increases the risk of developing ICI-associated myocarditis. Conclusion and Relevance This review aims to provide a standardized diagnostic and therapeutic approach for patients with suspected ICI-associated myocarditis. A complete history of recent cancer treatments and physical examination in combination with cardiac biomarkers, cardiac imaging, and endomyocardial biopsy represent a pragmatic diagnostic approach for most cases of ICI-associated myocarditis. The addition of novel biomarkers or imaging modalities is an area of active research and should be evaluated in larger cohorts.
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Affiliation(s)
- Lorenz H Lehmann
- Department of Cardiology, Angiology, and Pneumology, Cardio-Oncology Unit, Heidelberg University Hospital, Heidelberg, Germany.,German Centre for Cardiovascular Research, partner site Heidelberg/Mannheim, Heidelberg, Germany.,German Cancer Research Centre, Heidelberg, Germany
| | - Jennifer Cautela
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, France.,Groupe Méditerranéen de Cardio-Oncologie, Marseille, France.,Oncosafety Network of the Early Phases Cancer Trials Center, Marseille, France
| | - Nicolas Palaskas
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Alan H Baik
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Wouter C Meijers
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France.,Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Association Institut de Myologie, Centre de Recherche en Myologie, UMRS974, Paris, France
| | - Joachim Alexandre
- Department of Pharmacology, Normandie University, University of Caen Normandy, PICARO Cardio-oncology Program, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-Reperfusion Myocardique, Caen, France
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver J Müller
- Department of Internal Medicine III, University of Kiel, Kiel, Germany.,German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Mandar Aras
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Aarti H Asnani
- CardioVascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anita Deswal
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Michal Laufer-Perl
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Franck Thuny
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, France.,Groupe Méditerranéen de Cardio-Oncologie, Marseille, France
| | - Mathieu Kerneis
- Sorbonne Université, ACTION Study Group, Institut National de la Santé et de la Recherche Médicale, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Stéphane Ederhy
- Hôpitaux Universitaires Paris-Est, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Service de Cardiologie, Unico, Unité de Cardio-Oncologie, Groupe de Recherche Clinique en Cardio-Oncologie, Université Pierre et Marie Curie, Paris, France
| | - Joe-Elie Salem
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, UNICO-GRECO Cardio-Oncology Program, Pitié-Salpêtrière Hospital, Paris, France
| | - Javid J Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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66
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Baik AH, Oluwole OO, Johnson DB, Shah N, Salem JE, Tsai KK, Moslehi JJ. Mechanisms of Cardiovascular Toxicities Associated With Immunotherapies. Circ Res 2021; 128:1780-1801. [PMID: 33934609 PMCID: PMC8159878 DOI: 10.1161/circresaha.120.315894] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Immune-based therapies have revolutionized cancer treatments. Cardiovascular sequelae from these treatments, however, have emerged as critical complications, representing new challenges in cardio-oncology. Immune therapies include a broad range of novel drugs, from antibodies and other biologics, including immune checkpoint inhibitors and bispecific T-cell engagers, to cell-based therapies, such as chimeric-antigen receptor T-cell therapies. The recognition of immunotherapy-associated cardiovascular side effects has also catapulted new research questions revolving around the interactions between the immune and cardiovascular systems, and the signaling cascades affected by T cell activation, cytokine release, and immune system dysregulation. Here, we review the specific mechanisms of immune activation from immunotherapies and the resulting cardiovascular toxicities associated with immune activation and excess cytokine production.
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Affiliation(s)
- Alan H Baik
- Division of Cardiovascular Medicine, Department of Medicine, UCSF, San Francisco, CA (A.H.B.)
| | - Olalekan O Oluwole
- Division of Oncology (D.B.J., J.J.M., O.O.O.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Douglas B Johnson
- Division of Oncology (D.B.J., J.J.M., O.O.O.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nina Shah
- Division of Hematology and Oncology, Department of Medicine, UCSF, San Francisco, CA (N.S., K.K.T.)
| | - Joe-Elie Salem
- Department of Pharmacology, Cardio-oncology Program, CIC-1901, APHP.Sorbonne Université, Paris, France (J.-E.S.)
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-E.S., J.J.M.)
| | - Katy K Tsai
- Division of Hematology and Oncology, Department of Medicine, UCSF, San Francisco, CA (N.S., K.K.T.)
| | - Javid J Moslehi
- Division of Cardiovascular Medicine (J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Oncology (D.B.J., J.J.M., O.O.O.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-E.S., J.J.M.)
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67
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Cappelli LC, Bingham CO. Spectrum and impact of checkpoint inhibitor-induced irAEs. Nat Rev Rheumatol 2021; 17:69-70. [PMID: 33235330 DOI: 10.1038/s41584-020-00546-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Laura C Cappelli
- Johns Hopkins University School of Medicine, Division of Rheumatology, Baltimore, MD, USA.
| | - Clifton O Bingham
- Johns Hopkins University School of Medicine, Division of Rheumatology, Baltimore, MD, USA
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68
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Moslehi J, Lichtman AH, Sharpe AH, Galluzzi L, Kitsis RN. Immune checkpoint inhibitor-associated myocarditis: manifestations and mechanisms. J Clin Invest 2021; 131:145186. [PMID: 33645548 DOI: 10.1172/jci145186] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have transformed the treatment of various cancers, including malignancies once considered untreatable. These agents, however, are associated with inflammation and tissue damage in multiple organs. Myocarditis has emerged as a serious ICI-associated toxicity, because, while seemingly infrequent, it is often fulminant and lethal. The underlying basis of ICI-associated myocarditis is not completely understood. While the importance of T cells is clear, the inciting antigens, why they are recognized, and the mechanisms leading to cardiac cell injury remain poorly characterized. These issues underscore the need for basic and clinical studies to define pathogenesis, identify predictive biomarkers, improve diagnostic strategies, and develop effective treatments. An improved understanding of ICI-associated myocarditis will provide insights into the equilibrium between the immune and cardiovascular systems.
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Affiliation(s)
- Javid Moslehi
- Division of Cardiovascular Medicine and Division of Oncology, Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew H Lichtman
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Arlene H Sharpe
- Department of Immunology and Blavatnik Institute, Harvard Medical School, Boston, Massachusetts, USA.,Evergrande Center for Immunologic Diseases, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lorenzo Galluzzi
- Department of Radiation Oncology, Sandra and Edward Meyer Cancer Center, Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medical College, New York, New York, USA.,Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA.,Université de Paris, Paris, France
| | - Richard N Kitsis
- Departments of Medicine and Cell Biology, Wilf Family Cardiovascular Research Institute, and Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Bolz S, Ramakrishnan T, Fleischer M, Livingstone E, Stolte B, Thimm A, Kizina K, Ugurel S, Kleinschnitz C, Glas M, Zimmer L, Hagenacker T. Detect it so you can treat it: A case series and proposed checklist to detect neurotoxicity in checkpoint therapy. eNeurologicalSci 2021; 22:100324. [PMID: 33604462 PMCID: PMC7876540 DOI: 10.1016/j.ensci.2021.100324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/13/2020] [Accepted: 01/31/2021] [Indexed: 12/11/2022] Open
Abstract
Background Checkpoint inhibitors show impressive and durable responses in various cancer types and provide new avenues for cancer immunotherapy. However, these drugs have a variety of adverse events. Common autoimmune-related adverse effects include fatigue, hepatitis, skin rash, endocrine deficiencies, and colitis. Neurotoxicity has been reported, but its incidence and course remain unclear. Methods To illustrate the broad spectrum of neurotoxicity, we exemplarily report the neurological adverse events of five patients with melanoma and one patient with differentiated thyroid cancer who received checkpoint inhibitors at Essen University Hospital (Essen, Germany). Results After treatment with ipilimumab, nivolumab or pembrolizumab, neurotoxic effects included hypophysitis-associated neck pain and headache, Guillain-Barré syndrome, transverse myelitis, acute brachial plexus neuritis, and ocular myasthenia gravis. Conclusions Checkpoint inhibitor therapy remains a success story; however, neurological immune-related adverse events may cause severe life-threatening conditions. We propose a guide for the early detection of neurological adverse events during routine clinical treatment to prevent more severe courses of checkpoint inhibitor-induced neurotoxicity. We present neurological immune-related adverse events under checkpoint-inhibitors to underline the spectrums of manifestations. Neurological immune-related adverse events may cause severe life-threatening conditions. Practitioners should be aware of red flags symptoms to detect neurological immune-related adverse events
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Key Words
- AIDP, acute inflammatory demyelinating polyneuropathy
- CIDP, chronic inflammatory demyelinating polyneuropathy
- CNS, central nervous system
- CSF, cerebrospinal fluid
- Checkpoint inhibitor
- Guide
- ICI, immune checkpoint inhibitor
- IVIG, intravenous immunoglobulin
- Ipilimumab
- MG, Myasthenia Gravis
- MRI, magnetic resonance imaging
- Melanoma
- Neurotoxicity
- Nivolumab
- PD-L1, programmed cell death protein 1 ligand
- anti-CTLA-4, anti-cytotoxic T-lymphocyte-associated protein 4
- anti-PD-1, anti-programmed cell death protein 1
- i.v, intravenous
- irAE, immune-related adverse events
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Affiliation(s)
- Saskia Bolz
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Thivyah Ramakrishnan
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Michael Fleischer
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Elisabeth Livingstone
- Department of Dermatology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Benjamin Stolte
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Andreas Thimm
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Kathrin Kizina
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Tim Hagenacker
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
- Corresponding author at: Department of Neurology, University Hospital, Essen, Germany.
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70
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Sun Z, Wang S, Du H, Shen H, Zhu J, Li Y. Immunotherapy-induced pneumonitis in non-small cell lung cancer patients: current concern in treatment with immune-check-point inhibitors. Invest New Drugs 2021; 39:891-898. [PMID: 33428078 DOI: 10.1007/s10637-020-01051-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/10/2020] [Indexed: 12/22/2022]
Abstract
Purpose Immune-related adverse events (IrAEs) are auto-immune reactions associated with immune checkpoint inhibitor-based therapy (ICI). To date, little is known about immunotherapy-induced pneumonitis (IIP). In this study, we investigated the clinical and CT features of IIP in non-small cell lung cancer (NSCLC) patients treated with ICI. Methods CT images and clinical data of 98 NSCLC patients in our hospital were retrospectively analyzed after ICI therapy, and the incidence, onset time, CT findings, grade, treatment and prognosis of IIP were recorded. Results Nineteen patients developed IIP, which occurred 42∼210 days after ICI therapy, and the median time was 97 days. The CT findings for IIP showed multifocal ground-glass opacity (GGO) in 5 cases, patchy shadows in 6 cases, mixed distribution of patchy and strip-like shadows in 4 cases, and patchy shadows with honeycomb lung in 4 cases. The mean age and proportions of smokers, CD3+ and CD4+ of T lymphocyte subset in patients with IIP were significantly higher than those in patients without IIP (all p < 0.05). Among 19 patients with IIP, there were 10 patients with grade 1 ~ 2 and 9 patients with grade 3 ~ 4; 13 patients received hormone therapy, 12 of them were improved or stable, and 1 patient got worse after hormone therapy. No deaths from IIP were found. Conclusion IIP is a relatively rare but serious adverse event, and it is sensitive to hormone therapy. Its CT manifestations are diverse, and timely detection and treatment are the keys to reduce IIP.
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Affiliation(s)
- Zongqiong Sun
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, 215006, China
- Department of Radiology, Affiliated Hospital of Jiangnan University, Wuxi City, 214000, Jiangsu Province, China
| | - Sheng Wang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, 215006, China
| | - Hongdi Du
- Department of Radiology, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou City, Jiangsu Province, 215028, China
| | - Hailin Shen
- Department of Radiology, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou City, Jiangsu Province, 215028, China.
| | - Jingfen Zhu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, 215006, China.
| | - Yonggang Li
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, 215006, China.
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71
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Cappelli LC, Bingham CO. Expert Perspective: Immune Checkpoint Inhibitors and Rheumatologic Complications. Arthritis Rheumatol 2020; 73:553-565. [PMID: 33186490 DOI: 10.1002/art.41587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
Rheumatologists increasingly receive consults for patients treated with immune checkpoint inhibitors (ICIs) for cancer. ICIs can cause inflammatory syndromes known as immune-related adverse events (IRAEs). Several rheumatic IRAEs have been reported, including inflammatory arthritis, polymyalgia rheumatica, and myositis. For patients who present with musculoskeletal symptoms while receiving ICI therapy, it is important to have an algorithm for evaluation. The differential diagnosis includes a range of musculoskeletal syndromes, such as crystalline arthritis, mechanical issues, and osteoarthritis, in addition to IRAEs. After diagnosing a rheumatic IRAE, rheumatologists must work with the patient and the oncologist to form a treatment plan. Treatment of IRAEs is guided by severity. Evidence for management is limited to observational studies. Inflammatory arthritis and polymyalgia rheumatica are treated with nonsteroidal antiinflammatory drugs in mild cases, glucocorticoids for moderate-to-severe cases, and sometimes require other disease-modifying antirheumatic drugs. Myositis due to ICIs can be accompanied by myocarditis or myasthenia gravis. Glucocorticoids and withholding the ICI are usually required to treat myositis; some patients with severe myositis require intravenous immunoglobulin or plasmapheresis. Further research is needed to optimize treatment of IRAEs that does not compromise the antitumor effect of ICIs.
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72
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Efficacy of immunosuppressive therapy in myocarditis: A 30-year systematic review and meta analysis. Autoimmun Rev 2020; 20:102710. [PMID: 33197576 DOI: 10.1016/j.autrev.2020.102710] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/01/2020] [Indexed: 12/20/2022]
Abstract
AIMS Myocarditis is an inflammation of the heart muscle, due to infectious, toxic or autoimmune causes. Literature reported controversial results in relation to the effect of immunosuppression (IS)/immunomodulation (IM). We aimed at assessing the effect of IS/IM by meta analysis. METHODS AND RESULTS Using the P.R.I.S.M.A. approach, two researchers searched for relevant studies on PubMed, Embase, and the Central Registry of Controlled Trials of the Cochrane Library. Proposed MeSH terms were: "immunotherapy OR immune therapy OR immune modeling OR Immunosuppressive Agents" AND "combination OR combined with OR plus" AND "myocarditis OR cardiomyopathies OR inflammatory cardiomyopathy". The language was restricted to English. Reference lists of included articles and those relevant to the topic were hand searched for the identification of additional, potentially relevant articles. The cutoff date was from 1987 until 30th Nov 2019. Reported survival or mortality events or change of left ventricular ejection fraction (LVEF) after IS/IT were primary outcomes of the study; in addition, improvement of New York Heart Association class, follow-up biopsy (Bx) findings, viral genome clearance on Bx and recurrence of myocarditis were recorded if reported. Statistical analysis was conducted using Review Manager 5.3; 5452 studies were screened, of these 73 were assessed for eligibility, including 8 randomized control studies, 26 retrospective studies, 2 prospective studies and 1 case control study, 34 case reports and 2 case series. In prospective studies, the difference in mortality between the IS and control groups tended to be lower in the combined IS groups (12.5% vs. 18.2%) (95% CI of odds ratio 0.7(0.3, 1.64)) and the pooled difference of the increase of LVEF between the IS and control groups tended to be higher in the combined IS groups (95% CI 7.26 (-2.29, 16.81)). In retrospective studies, the difference of survival between the IS and control group was significantly in favor of IS (95%CI Hazard ratio 0.82(0.69, 0.96)). CONCLUSIONS A tailored IS may be considered in myocarditis, depending on the phase of the disease, and the type of underlying autoimmune or immune-mediated form.
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73
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Dey A, Manolios N, Long GV, Carlino MS, Kefford R, Schrieber L. Musculoskeletal immune-related adverse events with the use of checkpoint inhibitors in malignancy. Intern Med J 2020; 52:818-827. [PMID: 33135853 DOI: 10.1111/imj.15123] [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: 10/26/2019] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Immunotherapy has revolutionised the treatment of many malignancies. Along with their success, there have been inflammatory and immune-related adverse events (irAE). There is a paucity of literature describing the Australian experience of rheumatic irAE. AIMS To describe and characterise the Royal North Shore Hospital and Westmead Hospital cohort with rheumatic irAE. METHODS This case series reports on 17 patients with advanced cancer treated at two sites in Sydney, Australia who were referred for rheumatological evaluation from 2013 to 2016. Data were collected retrospectively and inspected for clinical signs, duration of immunotherapy prior to onset of symptoms, management strategies and cancer outcomes. RESULTS Patients presented with arthralgias, myalgias, periarticular and systemic symptoms. Onset of rheumatological symptoms was variable, with a median of 4 months (range 0.2-24) for monotherapy and 5.05 months (range 0.2-6.9) for combination. The predominant findings were of tenosynovitis (23%) and large joint involvement (65%). All patients were seronegative for RF and anti-CCP. Most patients responded well to non-steroidal anti-inflammatory drugs or low-dose prednisone (59%) and remained on immunotherapy (77%). The majority (76%) of patients experienced concomitant irAE in other organ systems. Sixty-five percent of patients had complete response of their malignancy to immunotherapy. CONCLUSION Rheumatic irAE are heterogenous clinical entities, which require further evaluation into classification, patient susceptibility and response. From our study, there was no clear clinical pattern. The present case series supports that rheumatic irAE may be associated with tumour response. However, there is still limited experience in rheumatic irAE management and outcomes.
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Affiliation(s)
- Abhishikta Dey
- Department of Rheumatology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nicholas Manolios
- Department of Rheumatology, Westmead Hospital and; Professor of Rheumatology, Faculty of Medicine and Health University of Sydney, The University of Sydney, Sydney, New South Wales, Australia
| | - Georgina V Long
- Department of Oncology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Melanoma Institute Australia, Sydney, New South Wales, Australia
| | - Matteo S Carlino
- Melanoma Institute Australia, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Richard Kefford
- Melanoma Institute Australia, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Leslie Schrieber
- Department of Rheumatology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Immune-related adverse events: a retrospective look into the future of oncology in the intensive care unit. Ann Intensive Care 2020; 10:143. [PMID: 33064239 PMCID: PMC7567777 DOI: 10.1186/s13613-020-00761-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023] Open
Abstract
Background Immune checkpoint inhibitors have reshaped the standard of care in oncology. However, they have been associated with potentially life-threatening immune-related adverse events. With the growing indications of immune checkpoint inhibitors and their position as a pillar of cancer treatment, intensive care physicians will be increasingly confronted with their side effects. The outcome of patients with severe immune-related adverse events in the intensive care unit remains unknown. This retrospective multicentric study aims to describe the characteristics of patients admitted to the intensive care units of 4 academic hospitals in Paris area while receiving immune checkpoint inhibitor treatment between January 2013 and October 2019. Results Over the study period, 112 cancer patients who received immune checkpoint inhibitors were admitted to the intensive care unit within 60 days after the last dose. ICU admission was related to immune-related adverse events (n = 29, 26%), other intercurrent events (n = 39, 35%), or complications related to tumor progression (n = 44, 39%). Immune-related adverse events were pneumonitis (n = 8), colitis (n = 4), myocarditis (n = 3), metabolic disorders related to diabetes (n = 3), hypophysitis (n = 2), nephritis (n = 2), meningitis or encephalitis (n = 2), hepatitis (n = 2), anaphylaxis (n = 2) and pericarditis (n = 1). Primary tumors were mostly melanomas (n = 14, 48%), non-small-cell lung cancers (n = 7, 24%), and urothelial carcinomas (n = 5, 17%). Diagnosis of melanoma and a neutrophil/lymphocyte ratio < 10 were associated with immune-related diagnosis versus other reasons for ICU admission. During their ICU stay, immune-related adverse events patients needed vasopressors (n = 7), mechanical ventilation (n = 6), and extra-corporeal membrane oxygenation (n = 2). One-year survival was significantly higher for patients admitted for irAE compared to patients admitted for other reasons (p = 0.004). Conclusions Admission to the intensive care unit related to immune-related adverse event was associated with better outcome in cancer patients treated with immune checkpoint inhibitors. Our results support the admission for an intensive care unit trial for patients with suspected immune-related adverse events.
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Immune checkpoint inhibitor-induced musculoskeletal manifestations. Rheumatol Int 2020; 41:33-42. [PMID: 32743706 DOI: 10.1007/s00296-020-04665-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibitors (ICI) associate with a wide range of immune-related adverse events (Ir-AE), including musculoskeletal manifestations. We aimed at identifying all studies reporting musculoskeletal Ir-AE. An electronic (Medline, Scopus and Web of Science) search was performed using two sets of key words. The first set consisted of: arthritis, musculoskeletal, polymyalgia rheumatica and myositis. The second set consisted of: anti-PD-1, anti-PD-L1, anti-CTLA-4, ipilimumab, tremelimumab, pembrolizumab, nivolumab, atezolizumab, avelumab and durvalumab. We identified 3 prospective studies, 17 retrospective studies and 4 case series reporting 363 patients in total. Combined data from all three prospective studies provide a prevalence rate of 6.13%. Most patients were males (59.68%) and the vast majority (73%) were on programmed death-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors. Most studies report a median time of ≤ 12 weeks from first ICI administration to symptom onset. The main clinical phenotypes reported were: (a) inflammatory arthritis (57.57%), (b) myositis (14.04%) and (c) polymyalgia rheumatica (PMR) (12.12%). A total of 256 patients required steroids (70.52%) and 67 patients (18.45%) were treated with DMARDs. Positive auto-antibodies and family history of any autoimmune disease were present in 18.48% and 19.04% of cases, respectively. Only a few patients (19%) had to discontinue treatment due to musculoskeletal Ir-AE. Two prospective studies show that significantly more patients with musculoskeletal Ir-AE exhibit a favorable oncologic response compared to patients not exhibiting such manifestations whereas retrospective studies show that 77.22% of patients with musculoskeletal Ir-AE have a good tumor response. One out of 15 patients treated with ICI will develop musculoskeletal Ir-AE; in most cases the severity of these manifestations is mild/moderate and usually ICI may be continued. Rheumatologists should familiarize with this new clinical entity and develop relevant therapeutic algorithms.
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