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Abstract
Several antineoplastic treatments have been responsible for thyroid dysfunction and thyroid eye disease. Min, Vaidya, and Becker (2011) reported a case of euthyroid Graves orbitopathy after treatment with ipilimumab with the patient displaying proptosis and myositis in the setting of normal thyroid function tests and elevated thyroid antibodies. The authors report a case of a 76-year-old woman who developed right upper lid retraction and proptosis after 2.5 years of treatment with lenalidomide for multiple myeloma. Thyroid function tests were normal: thyroid-stimulating hormone 0.808 mIU/mL, total T3 102 ng/dL, free T4 1.48 ng/dL. Thyroid antibodies were elevated: thyrotropin receptor antibody 2.26 IU/L, thyroglobulin antibody 1043.1 IU/mL, and thyroid peroxidase antibody 38 IU/mL. A nuclear medicine thyroid scan was normal. Given the possible thyroid effects from lenalidomide, patients who receive this medication should be periodically evaluated for thyroid dysfunction and thyroid eye disease.
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Sheldon CA, Kharlip J, Tamhankar MA. Inflammatory Orbitopathy Associated With Ipilimumab. Ophthalmic Plast Reconstr Surg 2017; 33:S155-S158. [PMID: 26068559 DOI: 10.1097/iop.0000000000000509] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In this case report, the clinical presentation of an inflammatory orbitopathy seen following treatment with ipilimumab is described. After 3 rounds of ipilimumab (10 mg/kg) treatment for Stage III metastatic melanoma, the subject of this case report developed acute eye pain and proptosis. At initial presentation, she had marked proptosis and diffuse severe ophthalmoparesis. After treatment with high-dose steroids, over a period of 6 months, the symptoms gradually resolved fully. Although the condition may mimic thyroid-associated orbitopathy, imaging and laboratory features suggest that the orbitopathy associated with ipilimumab is not a secondary effect of thyroid dysfunction but a distinct inflammatory condition. The authors conclude that immune-related side effects can occur with biologic agents used to treat malignancies and these side-effects can involve the eye. This case illustrates the occurrence of an inflammatory orbitopathy associated with ipilimumab treatment.
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Affiliation(s)
- Claire A Sheldon
- *Scheie Eye Institute, Department of Ophthalmology, and †Departments of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Abstract
PURPOSE OF REVIEW Significant advances have been made in oncology and rheumatology with the introduction of molecularly targeted agents (MTAs). MTAs consist of monoclonal antibodies and small molecule inhibitors. The purpose of this manuscript is to review the recent applications of MTAs to orbital, lacrimal, and eyelid disease. RECENT FINDINGS The use of monoclonal antibodies has been described in the treatment of orbital vascular lesions, lymphoma, and squamous cell carcinoma. Inflammatory conditions treated with monoclonal antibodies include thyroid eye disease, IgG4 disease, and granulomatosis with polyangiitis. Immunotherapy with checkpoint inhibitors has also found applications to orbital disease. Use of small molecule inhibitors has been described in the treatment of basal cell carcinoma, squamous cell carcinoma, and Erdheim-Chester disease. There are many orbital, lacrimal, and eyelid side effects of MTAs with which the oculoplastic surgeon should be familiar, including hypertrichosis, edema, and orbital and eyelid inflammation. SUMMARY MTAs represent the future of treatment of oncologic and inflammatory conditions. Application of these agents to orbital, lacrimal, and eyelid disease will continue to expand. Elucidating the molecular mechanisms of oculoplastic disorders will facilitate additional potential pathways that could be targeted for therapy.
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Abstract
PURPOSE OF REVIEW Checkpoint inhibitors have been increasingly considered as new targets for cancer therapies. Patients receiving checkpoint inhibitors develop many immune-related adverse events (IRAEs). However, ophthalmic IRAEs are rare and have been reported in less than 1% of patients. To date, few case reports evaluating the ophthalmological side-effects of checkpoint inhibitors have been published. In this review, we plan to report the different ocular and orbital side-effects of the checkpoint inhibitors, and to help guide ophthalmologists and oncologists in their management. RECENT FINDINGS Ocular side-effects of checkpoint inhibitors include peripheral ulcerative keratitis, uveitis, Vogt-Koyanagi-Harada syndrome, choroidal neovascularization and melanoma-associated retinopathy. Both thyroid-associated orbitopathy and idiopathic orbital inflammation have also been reported in association with checkpoint inhibitors. Mild IRAE can be treated with topical steroids, whereas systemic corticosteroids and discontinuation of checkpoint inhibitors are indicated in more severe ocular and orbital inflammation. SUMMARY Physicians involved in the care of oncologic patients should be aware of the ocular and orbital IRAEs that may develop with checkpoint inhibitors. A strong cooperation between oncologists and ophthalmologists is required in the diagnosis and prompt management of these IRAEs.
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Abstract
PURPOSE OF REVIEW Three mAbs targeting immune checkpoint proteins are available for the treatment of patients with melanoma, lung, and kidney cancer, and their use will likely expand in the future to additional tumor types. We here update the literature on the incidence and pathophysiology of endocrine toxicities induced by these agents, and discuss management guidance. RECENT FINDINGS Immune checkpoint inhibition may trigger autoimmune syndromes involving different organs, including several endocrine glands (pituitary, thyroid, adrenals, and endocrine pancreas). Hypophysitis is more frequently associated with ipilimumab, whereas the incidence of thyroid dysfunction is higher with nivolumab/pembrolizumab. Primary adrenal insufficiency can rarely occur with either treatment. Autoimmune diabetes is very rare. As hypophysitis and adrenalitis may be life-threatening, endocrinological evaluation is essential particularly in patients developing fatigue and other symptoms consistent with adrenal insufficiency. Corticosteroids should be promptly used when hypophysitis-induced adrenal insufficiency or adrenalitis are diagnosed, but not in thyroiditis or diabetes. No impact of corticosteroids on the efficacy/activity of immune checkpoint-inhibiting drugs is reported. Hormonal deficiencies are often permanent. SUMMARY In absence of predicting factors, accurate information to patients provided by the oncology care team is essential for early diagnosis and to limit the consequences of checkpoint inhibition-related endocrine toxicity.
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Morganstein DL, Lai Z, Spain L, Diem S, Levine D, Mace C, Gore M, Larkin J. Thyroid abnormalities following the use of cytotoxic T-lymphocyte antigen-4 and programmed death receptor protein-1 inhibitors in the treatment of melanoma. Clin Endocrinol (Oxf) 2017; 86:614-620. [PMID: 28028828 DOI: 10.1111/cen.13297] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/14/2016] [Accepted: 12/20/2016] [Indexed: 01/21/2023]
Abstract
CONTEXT Checkpoint inhibitors are emerging as important cancer therapies but are associated with a high rate of immune side effects, including endocrinopathy. OBJECTIVE To determine the burden of thyroid dysfunction in patients with melanoma treated with immune checkpoint inhibitors and describe the clinical course. DESIGN AND PATIENTS Consecutive patients with melanoma treated with either ipilimumab, nivolumab, pembrolizumab or the combination of ipilimumab and nivolumab were identified. Baseline thyroid function tests were used to exclude those with pre-existing thyroid abnormalities, and thyroid function tests during treatment used to identify those with thyroid dysfunction. RESULTS Rates of overt thyroid dysfunction were in keeping with the published phase 3 trials. Hypothyroidism occurred in 13·0% treated with a programmed death receptor-1 (PD-1) inhibitor and 22·2% with a combination of PD-1 inhibitor and ipilimumab. Transient subclinical hyperthyroidism was observed in 13·0% treated with a PD-1 inhibitor, 15·9% following a PD-1 inhibitor, and 22·2% following combination treatment with investigations suggesting a thyroiditic mechanism rather than Graves' disease, and a high frequency of subsequent hypothyroidism. Any thyroid abnormality occurred in 23·0% following ipilimumab, 39·1% following a PD-1 inhibitor and 50% following combination treatment. Abnormal thyroid function was more common in female patients. CONCLUSION Thyroid dysfunction occurs commonly in patients with melanoma treated with immune checkpoint inhibitors, with rates, including subclinical dysfunction, occurring in up to 50%.
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Affiliation(s)
- D L Morganstein
- Skin Unit, Royal Marsden Hospital, London, UK
- Department of Endocrinology, Chelsea and Westminster Hospital, London, UK
| | - Z Lai
- Skin Unit, Royal Marsden Hospital, London, UK
- Department of Endocrinology, Chelsea and Westminster Hospital, London, UK
| | - L Spain
- Skin Unit, Royal Marsden Hospital, London, UK
| | - S Diem
- Skin Unit, Royal Marsden Hospital, London, UK
- Department of Oncology/Hematology, Cantonal Hospital St. Gallen, Switzerland, Switzerland
- Department of Oncology/Hematology, Hospital Grabs, Switzerland
| | - D Levine
- Department of Nuclear Medicine, Royal Marsden Hospital, London, UK
| | - C Mace
- Department of Endocrinology, Chelsea and Westminster Hospital, London, UK
| | - M Gore
- Skin Unit, Royal Marsden Hospital, London, UK
| | - J Larkin
- Skin Unit, Royal Marsden Hospital, London, UK
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Byun DJ, Wolchok JD, Rosenberg LM, Girotra M. Cancer immunotherapy - immune checkpoint blockade and associated endocrinopathies. Nat Rev Endocrinol 2017; 13:195-207. [PMID: 28106152 PMCID: PMC5629093 DOI: 10.1038/nrendo.2016.205] [Citation(s) in RCA: 443] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Advances in cancer therapy in the past few years include the development of medications that modulate immune checkpoint proteins. Cytotoxic T-lymphocyte antigen 4 (CTLA4) and programmed cell death protein 1 (PD1) are two co-inhibitory receptors that are expressed on activated T cells against which therapeutic blocking antibodies have reached routine clinical use. Immune checkpoint blockade can induce inflammatory adverse effects, termed immune-related adverse events (IRAEs), which resemble autoimmune disease. In this Review, we describe the current data regarding immune-related endocrinopathies, including hypophysitis, thyroid dysfunction and diabetes mellitus. We discuss the clinical management of these endocrinopathies within the context of our current understanding of the mechanisms of IRAEs.
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Affiliation(s)
- David J Byun
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, 10065 New York, USA
- Weill Cornell Medical College, 1300 York Avenue, New York, 10065 New York, USA
| | - Jedd D Wolchok
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, 10065 New York, USA
- Weill Cornell Medical College, 1300 York Avenue, New York, 10065 New York, USA
| | - Lynne M Rosenberg
- Weill Cornell Medical College, 1300 York Avenue, New York, 10065 New York, USA
| | - Monica Girotra
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, 10065 New York, USA
- Weill Cornell Medical College, 1300 York Avenue, New York, 10065 New York, USA
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Vouk K, Benter U, Amonkar MM, Marocco A, Stapelkamp C, Pfersch S, Benjamin L. Cost and economic burden of adverse events associated with metastatic melanoma treatments in five countries. J Med Econ 2016; 19:900-12. [PMID: 27123564 DOI: 10.1080/13696998.2016.1184155] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To estimate per-event cost and economic burden associated with managing the most common and/or severe metastatic melanoma (MM) treatment-related adverse events (AEs) in Australia, France, Germany, Italy, and the UK. METHODS AEs associated with chemotherapy (dacarbazine, paclitaxel, fotemustine), immunotherapy (ipilimumab), and targeted therapy (vemurafenib) were identified by literature review. Medical resource use data associated with managing AEs were collected through two blinded Delphi panel cycles in each of the five countries. Published costs were used to estimate per-event costs and combined with AEs incidence, treatment usage, and MM prevalence to estimate the economic burden for each country. RESULTS The costliest AEs were grade 3/4 events due to immunotherapy (Australia/France: colitis; UK: diarrhea) and chemotherapy (Germany/Italy: neutropenia/leukopenia). Treatment of AEs specific to chemotherapy (Australia/Germany/Italy/France: neutropenia/leukopenia) and targeted therapy (UK: squamous cell carcinoma) contributed heavily to country-specific economic burden. LIMITATIONS Economic burden was estimated assuming that each patient experienced an AE only once. In addition, the context of settings was heterogeneous and the number of Delphi panel experts was limited. CONCLUSIONS Management costs for MM treatment-associated AEs can be substantial. Results could be incorporated in economic models that support reimbursement dossiers. With the availability of newer treatments, establishment of a baseline measure of the economic burden of AEs will be crucial for assessing their impact on patients and regional healthcare systems.
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Affiliation(s)
| | | | | | | | | | - Sylvie Pfersch
- e Novartis Pharma S.A.S. , Rueil-Malmaison Cedex , France
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Joshi MN, Whitelaw BC, Palomar MTP, Wu Y, Carroll PV. Immune checkpoint inhibitor-related hypophysitis and endocrine dysfunction: clinical review. Clin Endocrinol (Oxf) 2016; 85:331-9. [PMID: 26998595 DOI: 10.1111/cen.13063] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 12/23/2015] [Accepted: 03/06/2016] [Indexed: 12/12/2022]
Abstract
Immune checkpoint inhibitors are a new and effective class of cancer therapy, with ipilimumab being the most established drug in this category. The drugs' mechanism of action includes promoting the effector T cell response to tumours and therefore increased autoimmunity is a predictable side effect. The endocrine effects of these drugs include hypophysitis and thyroid dysfunction, with rare reports of adrenalitis. The overall incidence of hypophysitis with these medications is up to 9%. Primary thyroid dysfunction occurs in up to 15% of patients, with adrenalitis reported in approximately 1%. The mean onset of endocrine side effects is 9 weeks after initiation (range 5-36 weeks). Investigation and/or screening for hypophysitis requires biochemical and radiological assessment. Hypopituitarism is treated with replacement doses of deficient hormones. Since the endocrine effects of immune checkpoint inhibitors are classed as toxic adverse events, most authors recommend both discontinuation of the immune checkpoint inhibiting medication and 'high-dose' glucocorticoid treatment. However, this has been challenged by some authors, particularly if the endocrine effects can be managed (e.g. pituitary hormone deficiency), and the therapy is proving effective as an anticancer agent. This review describes the mechanism of action of immune checkpoint inhibitors and details the key clinical endocrine-related consequences of this novel class of immunotherapies.
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Affiliation(s)
- M N Joshi
- Departments of Endocrinology, Guy's & St Thomas NHS Foundation Trust, London, UK
| | - B C Whitelaw
- Department of Endocrinology, Kings College London NHS Foundation Trust, London, UK
| | - M T P Palomar
- Medical Oncology, Guy's & St Thomas NHS Foundation Trust, London, UK
| | - Y Wu
- Medical Oncology, Guy's & St Thomas NHS Foundation Trust, London, UK
| | - P V Carroll
- Departments of Endocrinology, Guy's & St Thomas NHS Foundation Trust, London, UK
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60
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Matsuzawa K, Izawa S, Okura T, Fujii S, Matsumoto K, Shoji K, Nakamura R, Sumi K, Fujioka Y, Yoshida A, Shigemasa C, Kato M, Yamamoto K, Taniguchi SI. Implications of FoxP3-positive and -negative CD4(+) CD25(+) T cells in Graves' ophthalmopathy. Endocr J 2016; 63:755-64. [PMID: 27349268 DOI: 10.1507/endocrj.ej16-0108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Graves' ophthalmopathy (GO) is a common manifestation of Graves' disease (GD); however, its pathogenesis is not well understood. Recently, the dysregulation of regulatory T cells (Tregs) has been thought to be closely associated with the pathogenesis and clinical symptoms of autoimmune disease. We therefore evaluated whether T cell subsets, including Tregs, are associated with GO pathogenesis and clinical symptoms. In this observational study we evaluated 35 GD patients with overt ophthalmopathy (GOs) and 28 patients without ophthalmopathy (non-GOs). Fifteen healthy euthyroid patients served as healthy controls (HCs). Peripheral blood mononuclear cells from GOs, non-GOs and HCs were analyzed for CD4, CD25, and FoxP3 expression using flow cytometry. We also evaluated their correlation with disease activity according to the clinical activity score (CAS) and magnetic resonance imaging (MRI) findings. Disease severity was evaluated using the NOSPECS score, and clinical progression of GO was followed for 24 weeks. The main outcome measures were the frequencies of FoxP3-positive and -negative CD4(+) CD25(+) T cells at study outset, namely Tregs and effector T cells (Teffs), respectively. GOs had higher frequencies of Teffs (30.8±8.4%) than non-GOs (19.4±7.1%) and HCs (22.7±7.9%). Notably, patients with improved GOs had lower frequencies of Tregs (5.8±1.1%) than patients with stable or deteriorated GOs (7.3±1.2%), although ophthalmic and radiological parameters were not significantly different at the start of the study. In conclusion, an expanded Teff population may be associated with GO pathogenesis. Additionally, decreased Tregs in peripheral blood may predict a good clinical outcome.
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Affiliation(s)
- Kazuhiko Matsuzawa
- Department of Regional Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
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Kähler KC, Hassel JC, Heinzerling L, Loquai C, Mössner R, Ugurel S, Zimmer L, Gutzmer R. Nebenwirkungsmanagement bei Immun-Checkpoint-Blockade durch CTLA-4- und PD1-Antikörper beim metastasierten Melanom. J Dtsch Dermatol Ges 2016; 14:662-83. [PMID: 27373240 DOI: 10.1111/ddg.13047_g] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Katharina C Kähler
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Klinik für Dermatologie, Venerologie und Allergologie
| | - Jessica C Hassel
- Universitätsklinikum Heidelberg, Hautklinik und Nationales Centrum für Tumorerkrankungen
| | | | - Carmen Loquai
- Hautklinik und Poliklinik, Universitätsmedizin Mainz
| | - Rotraut Mössner
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen
| | - Selma Ugurel
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen
| | - Lisa Zimmer
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen
| | - Ralf Gutzmer
- Hauttumorzentrum Hannover, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
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62
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González-Rodríguez E, Rodríguez-Abreu D. Immune Checkpoint Inhibitors: Review and Management of Endocrine Adverse Events. Oncologist 2016; 21:804-16. [PMID: 27306911 PMCID: PMC4943391 DOI: 10.1634/theoncologist.2015-0509] [Citation(s) in RCA: 168] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 02/19/2016] [Indexed: 12/11/2022] Open
Abstract
UNLABELLED : In recent years, immune checkpoint inhibitors have emerged as effective therapies for advanced neoplasias. As new checkpoint target blockers become available and additional tumor locations tested, their use is expected to increase within a short time. Immune-related adverse events (irAEs) affecting the endocrine system are among the most frequent and complex toxicities. Some may be life-threatening if not recognized; hence, appropriate guidance for oncologists is needed. Despite their high incidence, endocrine irAEs have not been fully described for all immunotherapy agents available. This article is a narrative review of endocrinopathies associated with cytotoxic T lymphocyte-associated antigen-4, blockade of programmed death receptor 1 and its ligand inhibitors, and their combination. Thyroid dysfunction is the most frequent irAE reported, and hypophysitis is characteristic of ipilimumab. Incidence, timing patterns, and clinical presentation are discussed, and practical recommendations for clinical management are suggested. Heterogeneous terminology and lack of appropriate resolution criteria in clinical trials make adequate evaluation of endocrine AEs difficult. It is necessary to standardize definitions to contrast incidences and characterize toxicity patterns. To provide optimal care, a multidisciplinary team that includes endocrinology specialists is recommended. IMPLICATIONS FOR PRACTICE Immune checkpoint inhibitors are already part of oncologists' therapeutic arsenal as effective therapies for otherwise untreatable neoplasias, such as metastatic melanoma or lung cancer. Their use is expected to increase exponentially in the near future as additional agents become available and their approval is extended to different tumor types. Adverse events affecting the endocrine system are among the most frequent and complex toxicities oncologists may face, and some may be life-threatening if not recognized. This study reviews endocrinopathies associated to immune checkpoint inhibitors available to date. Incidence, timing patterns, and clinical presentation are discussed, and practical recommendations for management are proposed.
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Affiliation(s)
- Elisa González-Rodríguez
- Section of Endocrinology and Nutrition, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Delvys Rodríguez-Abreu
- Section of Medical Oncology, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
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63
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Wick MR, Gru AA. Metastatic melanoma: Pathologic characterization, current treatment, and complications of therapy. Semin Diagn Pathol 2016; 33:204-18. [PMID: 27234321 DOI: 10.1053/j.semdp.2016.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Metastatic melanoma (MM) has the potential to involve virtually any anatomical site, and it also has a wide spectrum of histological appearances. General clinicopathologic data pertaining to MM are presented in this review, together with a discussion of its differential diagnosis and therapy. "Biological" agents used in the treatment of melanoma are considered, along with the pathological features of the complications that they may cause.
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Affiliation(s)
- Mark R Wick
- Division of Surgical Pathology & Cytopathology, University of Virginia Medical Center, Charlottesville, Virginia.
| | - Alejandro A Gru
- Division of Surgical Pathology & Cytopathology, University of Virginia Medical Center, Charlottesville, Virginia
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64
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Henderson AD, Thomas DA. A case report of orbital inflammatory syndrome secondary to ipilimumab. Ophthalmic Plast Reconstr Surg 2016; 31:e68-70. [PMID: 24814274 DOI: 10.1097/iop.0000000000000081] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ipilimumab is a monoclonal antibody to cytotoxic T-lymphocyte antigen-4, a negative regulator of T-cell-mediated immune response. Ipilimumab is approved by the US Food and Drug Administration for the treatment of advanced melanoma. However, its use frequently has been associated with immune-related side effects, which can be explained by its mechanism of action. More common adverse effects include dermatitis, colitis, hepatitis, and endocrinopathies, but many less common immune-related adverse effects that involve various tissues and organ systems have been reported with more widespread use of ipilimumab since its approval in 2011. A case of bilateral orbital inflammatory syndrome secondary to ipilimumab, in a patient undergoing adjuvant treatment for metastatic melanoma, is reported.
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Affiliation(s)
- Amanda D Henderson
- Department of Ophthalmology, Georgia Regents University, Augusta, Georgia, U.S.A
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Rossi E, Sgambato A, De Chiara G, Casaluce F, Losanno T, Sacco PC, Santabarbara G, Gridelli C. Endocrinopathies induced by immune-checkpoint inhibitors in advanced non-small cell lung cancer. Expert Rev Clin Pharmacol 2016; 9:419-28. [PMID: 26681547 DOI: 10.1586/17512433.2016.1133289] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The advent of immunotherapy has recently expanded the therapeutic options in advanced non-small cell lung cancer (NSCLC). In these patients, the recent efficacy demonstration of antibodies against immune checkpoints: the anti-programmed death-1 (PD-1) and anti-programmed death ligand-1 (PD-L1), has led to approval of nivolumab and pembrolizumab (anti-PD-1) in the treatment of advanced NSCLC. The mechanism of action of checkpoint inhibitors explains the development of autoimmune diseases as a side-effect of these medications. Among these, a spectrum of endocrine disorders has been also reported. This manuscript focuses particularly on endocrine disorders induced by immuno-checkpoint inhibitors employed in NSCLC, in order to suggest the strategies for their diagnosis and effective management.
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Affiliation(s)
- Emanuela Rossi
- a Division of Medical Oncology , "S. G. Moscati" Hospital , Avellino , Italy
| | - Assunta Sgambato
- b Department of Clinical and Experimental Medicine , Second University of Naples , Naples , Italy
| | - Giovanni De Chiara
- c Division of Pathologic Anatomy , "S. G. Moscati" Hospital , Avellino , Italy
| | - Francesca Casaluce
- b Department of Clinical and Experimental Medicine , Second University of Naples , Naples , Italy
| | - Tania Losanno
- d Department of Experimental Medicine , "Sapienza" University , Rome , Italy
| | - Paola Claudia Sacco
- a Division of Medical Oncology , "S. G. Moscati" Hospital , Avellino , Italy
| | | | - Cesare Gridelli
- a Division of Medical Oncology , "S. G. Moscati" Hospital , Avellino , Italy
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Naidoo J, Page DB, Li BT, Connell LC, Schindler K, Lacouture ME, Postow MA, Wolchok JD. Toxicities of the anti-PD-1 and anti-PD-L1 immune checkpoint antibodies. Ann Oncol 2015; 26:2375-91. [PMID: 26371282 PMCID: PMC6267867 DOI: 10.1093/annonc/mdv383] [Citation(s) in RCA: 990] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/01/2015] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint antibodies that augment the programmed cell death protein 1 (PD-1)/PD-L1 pathway have demonstrated antitumor activity across multiple malignancies, and gained recent regulatory approval as single-agent therapy for the treatment of metastatic malignant melanoma and nonsmall-cell lung cancer. Knowledge of toxicities associated with PD-1/PD-L1 blockade, as well as effective management algorithms for these toxicities, is pivotal in order to optimize clinical efficacy and safety. In this article, we review selected published and presented clinical studies investigating single-agent anti-PD-1/PD-L1 therapy and trials of combination approaches with other standard anticancer therapies, in multiple tumor types. We summarize the key adverse events reported in these studies and their management algorithms.
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Affiliation(s)
- J Naidoo
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore
| | - D B Page
- Providence Portland Medical Center and Earl A. Chiles Research Institute, Portland
| | - B T Li
- Department of Medicine and Ludwig Center, Memorial Sloan Kettering Cancer Center, New York, USA
| | - L C Connell
- Department of Medicine and Ludwig Center, Memorial Sloan Kettering Cancer Center, New York, USA
| | - K Schindler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - M E Lacouture
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York Department of Medicine, Weill Cornell Medical College, New York, USA
| | - M A Postow
- Department of Medicine and Ludwig Center, Memorial Sloan Kettering Cancer Center, New York, USA Department of Medicine, Weill Cornell Medical College, New York, USA
| | - J D Wolchok
- Department of Medicine and Ludwig Center, Memorial Sloan Kettering Cancer Center, New York, USA Department of Medicine, Weill Cornell Medical College, New York, USA
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67
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Rousseau A, Labetoulle M. Effets indésirables oculaires des traitements systémiques : une mise à jour. J Fr Ophtalmol 2015; 38:876-82. [DOI: 10.1016/j.jfo.2015.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 05/27/2015] [Indexed: 02/07/2023]
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68
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Immune-mediated adverse events of anticytotoxic T lymphocyte-associated antigen 4 antibody therapy in metastatic melanoma. Transl Res 2015; 166:412-24. [PMID: 26118951 PMCID: PMC4609598 DOI: 10.1016/j.trsl.2015.06.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 06/02/2015] [Accepted: 06/04/2015] [Indexed: 12/17/2022]
Abstract
Ipilimumab, an antibody that blocks cytotoxic T lymphocyte-associated antigen 4 (CTLA-4; CD152), was approved by the Food and Drug Administration in 2011 for the treatment of unresectable stage III or IV malignant melanoma. Although the addition of this particular immunotherapy has broadened treatment options, immune-related adverse events (irAEs) are associated with ipilimumab therapy, including dermatologic effects, colitis and diarrhea, endocrine effects, hepatotoxicity, ocular effects, renal effects, neurologic effects, and others. In this article, a critical evaluation of the underlying mechanisms of irAEs associated with anti-CTLA-4 therapy is presented. Additionally, potentially beneficial effects of combinational therapies to alleviate ipilimumab-induced irAEs in malignant melanoma are discussed. Future research is warranted to elucidate the efficacy of such combination therapies and specific biomarkers that would help to predict a clinical response to ipilimumab in patients with malignant melanoma.
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Miserocchi E, Cimminiello C, Mazzola M, Russo V, Modorati GM. New-onset uveitis during CTLA-4 blockade therapy with ipilimumab in metastatic melanoma patient. Can J Ophthalmol 2015; 50:e2-4. [PMID: 25677296 DOI: 10.1016/j.jcjo.2014.10.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/25/2014] [Accepted: 10/01/2014] [Indexed: 02/05/2023]
Affiliation(s)
| | | | - Marco Mazzola
- San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Vincenzo Russo
- San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Giulio M Modorati
- San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
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Carl D, Grüllich C, Hering S, Schabet M. Steroid responsive encephalopathy associated with autoimmune thyroiditis following ipilimumab therapy: a case report. BMC Res Notes 2015. [PMID: 26209970 PMCID: PMC4514969 DOI: 10.1186/s13104-015-1283-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Ipilimumab is a cytotoxic T-lymphocyte-associated protein 4 receptor antibody used for immunotherapy in cancer. Several immune-related adverse events are known. Steroid responsive encephalopathy associated with autoimmune thyroiditis is an autoimmune encephalopathy associated with Hashimoto’s Disease and elevated serum levels of the related antibodies (anti-thyroid-peroxidase antibody or anti-thyroglobulin antibody). Our case implies that steroid responsive encephalopathy associated with autoimmune thyroiditis may be another previously unreported side effect of ipilimumab therapy. Case presentation We report the case of a 64 years old caucasian patient with prostatic cancer who received ipilimumab therapy in a clinical trial. He presented with aphasia, tremor and ataxia, myocloni, hallucinations, anxiety and agitation in turns with somnolence. Cranial nerves, deep tendon reflexes, motor and sensory functions were normal. Electroencephalography showed background slowing but no epileptic discharges. Brain magnetic resonance imaging was normal and showed no signs of hypophysitis. Cerebrospinal fluid findings ruled out infection and neoplastic meningitis. Anti-thyroid antibodies (anti-thyroid-peroxidase antibody and anti-thyroglobulin antibody) were heavily increased. Assuming steroid responsive encephalopathy associated with autoimmune thyroiditis the patient was treated with 1,000 mg methylprednisolone i.v. for 3 days and continued with 1 mg/kg orally. On the 3rd day of treatment the patient’s condition started to improve. Within the next few days he gradually returned to his previous state, and electroencephalography eventually showed only slight slowing. Seven months later the patient’s condition was stable, and anti-thyroid antibodies were no more detectable. Conclusion Steroid responsive encephalopathy associated with autoimmune thyroiditis may be a hitherto unrecognized complication of ipililumab treatment and should be taken into consideration in patients developing central nervous symptoms undergoing this treatment.
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Affiliation(s)
- David Carl
- Department of Neurology, Klinikum Ludwigsburg, Posilipostraße 4, Ludwigsburg, Germany.
| | | | - Steffen Hering
- Department of Internal Medicine, Klinikum Bietigheim, Bietigheim-Bissingen, Germany.
| | - Martin Schabet
- Department of Neurology, Klinikum Ludwigsburg, Posilipostraße 4, Ludwigsburg, Germany.
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Papavasileiou E, Prasad S, Freitag SK, Sobrin L, Lobo AM. Ipilimumab-induced Ocular and Orbital Inflammation—A Case Series and Review of the Literature. Ocul Immunol Inflamm 2015; 24:140-6. [DOI: 10.3109/09273948.2014.1001858] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Yu C, Chopra IJ, Ha E. A novel melanoma therapy stirs up a storm: ipilimumab-induced thyrotoxicosis. Endocrinol Diabetes Metab Case Rep 2015; 2015:140092. [PMID: 25759760 PMCID: PMC4330494 DOI: 10.1530/edm-14-0092] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 01/26/2015] [Indexed: 11/23/2022] Open
Abstract
Ipilimumab, a novel therapy for metastatic melanoma, inhibits cytotoxic T-lymphocyte apoptosis, causing both antitumor activity and significant autoimmunity, including autoimmune thyroiditis. Steroids are frequently used in treatment of immune-related adverse events; however, a concern regarding the property of steroids to reduce therapeutic antitumor response exists. This study describes the first reported case of ipilimumab-associated thyroid storm and implicates iopanoic acid as an alternative therapy for immune-mediated adverse effects. An 88-year-old woman with metastatic melanoma presented with fatigue, anorexia, decreased functional status, and intermittent diarrhea for several months, shortly after initiation of ipilimumab – a recombinant human monoclonal antibody to the cytotoxic T-lymphocyte-associated antigen 4 (CTLA4). On arrival, she was febrile, tachycardic, and hypertensive with a wide pulse pressure, yet non-toxic appearing. She had diffuse, non-tender thyromegaly. An electrocardiogram (EKG) revealed supraventricular tachycardia. Blood, urine, and stool cultures were collected, and empiric antibiotics were started. A computed tomography (CT) angiogram of the chest was negative for pulmonary embolism or pneumonia, but confirmed a diffusely enlarged thyroid gland, which prompted thyroid function testing. TSH was decreased at 0.16 μIU/ml (normal 0.3–4.7); free tri-iodothyronine (T3) was markedly elevated at 1031 pg/dl (normal 249–405), as was free thyroxine (T4) at 5.6 ng/dl (normal 0.8–1.6). With iopanoic acid and methimazole therapy, she markedly improved within 48 h, which could be attributed to lowering of serum T3 with iopanoic acid rather than to any effect of the methimazole. Ipilimumab is a cause of overt thyrotoxicosis and its immune-mediated adverse effects can be treated with iopanoic acid, a potent inhibitor of T4-to-T3 conversion.
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Affiliation(s)
- Christine Yu
- Department of Medicine, University of California , Los Angeles, Los Angeles, California, 90095 , USA
| | - Inder J Chopra
- Division of Endocrinology, Department of Medicine, University of California , 757 Westwood Plaza Blvd, Suite 7501, Los Angeles, CA, 90095 , USA
| | - Edward Ha
- Department of Medicine, University of California , Los Angeles, Los Angeles, California, 90095 , USA
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Disturbances of modulating molecules (FOXP3, CTLA-4/CD28/B7, and CD40/CD40L) mRNA expressions in the orbital tissue from patients with severe graves' ophthalmopathy. Mediators Inflamm 2015; 2015:340934. [PMID: 25653477 PMCID: PMC4306377 DOI: 10.1155/2015/340934] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/13/2014] [Accepted: 08/18/2014] [Indexed: 01/16/2023] Open
Abstract
Purpose. To evaluate the relationship between the expression of orbital tissue mRNA for FOXP3, CTLA-4/CD28/CD80/CD86, and CD40/CD40 and the severity of Graves' orbitopathy (GO). Material and Methods. Orbital tissue was obtained from 26 patients with GO, with mild (n = 6) or severe GO (n = 20), and 7 healthy controls. The expression of mRNA of FOXP3, CTLA-4/CD28/CD80/CD86, CD40/CD40L was measured by RT-PCR. TCR and CD3 were evaluated by immunohistochemistry. Results. Higher mRNA for FoxP3 (relative expression: 1.4) and CD40 (1.27) and lower expression of CTLA-4 (0.61) were found in the GO tissues versus controls. In severe GO as compared to mild GO higher mRNA expression for FoxP3 (1.35) and CD40 (1.4) and lower expression for CTLA-4 (0.78), CD28 (0.62), and CD40L (0.56) were found. A positive correlation was found between FOXP3 mRNA and CD3 infiltration (R = 0.796, P = 0.0000001). Conclusions. The enhanced FOXP3 mRNA expression in GO samples may suggest the dysfunction of FOXP3 cells in the severe GO. The diminished mRNA expression of CTLA-4 in severe GO may indicate inadequate T regulatory function. The enhanced mRNA expression of CD40 in severe GO and negative correlation to CRP mRNA may suggest their role in the active and inactive GO.
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McElnea E, Ní Mhéalóid A, Moran S, Kelly R, Fulcher T. Thyroid-like ophthalmopathy in a euthyroid patient receiving Ipilimumab. Orbit 2014; 33:424-7. [PMID: 25207976 DOI: 10.3109/01676830.2014.949792] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 68-year-old lady with metastatic malignant melanoma was treated with Ipilimumab. She presented to Eye Casualty unable to move her eyes. Physical examination confirmed ophthalmoplegia and identified proptosis bilaterally. Radiological imaging showed bilateral enlargement of all the extra-ocular muscles suggestive of thyroid eye disease. Laboratory investigations found this patient to be euthyroid. A diagnosis of thyroid-like orbitopathy secondary to Ipilimumab therapy was made. Thyroid function tests should be performed for all patients prior to their commencement of Ipilimumab. Thyroid-like eye disease may develop in patients treated with Ipilimumab even if they remain euthyroid.
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Affiliation(s)
- Elizabeth McElnea
- Department of Ophthalmology, Mater Misericordiae University Hospital , Dublin , Ireland
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Ipilimumab-induced orbital inflammation resembling Graves disease with subsequent development of systemic hyperthyroidism from CTLA-4 receptor suppression. Ophthalmic Plast Reconstr Surg 2014; 30:83. [PMID: 24398505 DOI: 10.1097/iop.0000000000000033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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76
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Kheir WJ, Sniegowski MC, El-Sawy T, Li A, Esmaeli B. Ophthalmic complications of targeted cancer therapy and recently recognized ophthalmic complications of traditional chemotherapy. Surv Ophthalmol 2014; 59:493-502. [PMID: 25130892 DOI: 10.1016/j.survophthal.2014.02.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 02/09/2014] [Accepted: 02/12/2014] [Indexed: 12/14/2022]
Abstract
As our understanding of cancer pathophysiology has increased, so have the number of targeted therapeutic agents available. By targeting specific molecules involved in tumorigenesis, targeted therapeutic agents offer the potential for significant efficacy against tumor cells while minimizing the adverse effects. We highlight the recently recognized ophthalmic complications of targeted cancer therapy, as well as recently recognized complications of traditional chemotherapeutic agents.
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Affiliation(s)
- Wajiha J Kheir
- Orbital Oncology and Ophthalmic Plastic Surgery Program, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas; American University of Beirut Medical Center, Beirut, Lebanon
| | - Matthew C Sniegowski
- Orbital Oncology and Ophthalmic Plastic Surgery Program, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tarek El-Sawy
- Orbital Oncology and Ophthalmic Plastic Surgery Program, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Ophthalmology, Stanford University, Palo Alto, California
| | - Alexa Li
- Orbital Oncology and Ophthalmic Plastic Surgery Program, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bita Esmaeli
- Orbital Oncology and Ophthalmic Plastic Surgery Program, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Reply Re: "Drug-induced Graves disease from CTLA-4 receptor suppression". Ophthalmic Plast Reconstr Surg 2013; 29:241. [PMID: 23652295 DOI: 10.1097/iop.0b013e31828957c3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Torino F, Barnabei A, Paragliola R, Baldelli R, Appetecchia M, Corsello SM. Thyroid dysfunction as an unintended side effect of anticancer drugs. Thyroid 2013; 23:1345-66. [PMID: 23750887 DOI: 10.1089/thy.2013.0241] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Several of the currently used anticancer drugs may variably affect thyroid function, with impairment ranging from modified total but not free concentration of thyroid hormones to overt thyroid disease. SUMMARY Cytotoxic agents seem to alter thyroid function in a relatively small proportion of adult patients. Anticancer hormone drugs may mainly alter serum levels of thyroid hormone-binding proteins without clinically relevant thyroid dysfunction. Old immunomodulating drugs, such as interferon-α and interleukin-2, are known to induce variably high incidence of autoimmune thyroid dysfunction. Newer immune checkpoint inhibitors, such as anti-CTLA4 monoclonal antibodies, are responsible for a relatively low incidence of thyroiditis and may induce secondary hypothyroidism resulting from hypophysitis. Central hypothyroidism is a well-recognized side effect of bexarotene. Despite their inherent selectivity, tyrosine kinase inhibitors may cause high rates of thyroid dysfunction. Notably, thyroid toxicity seems to be restricted to tyrosine kinase inhibitors targeting key kinase-receptors in angiogenic pathways, but not other kinase-receptors (e.g., epidermal growth factor receptors family or c-KIT). In addition, a number of these agents may also increase the levothyroxine requirement in thyroidectomized patients. CONCLUSIONS The pathophysiology of thyroid toxicity induced by many anticancer agents is not fully clarified and for others it remains speculative. Thyroid dysfunction induced by anticancer agents is generally manageable and dose reduction or discontinuation of these agents is not required. The prognostic relevance of thyroid autoimmunity, overt and subclinical hypothyroidism induced by anticancer drugs, the value of thyroid hormone replacement in individuals with abnormal thyrotropin following anticancer systemic therapy, and the correct timing of replacement therapy in cancer patients need to be defined more accurately in well-powered prospective clinical trials.
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Affiliation(s)
- Francesco Torino
- 1 Department of Systems Medicine, Tor Vergata University of Rome , Rome, Italy
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Ipilimumab-induced endocrinopathies: when to start corticosteroids (or not). Cancer Chemother Pharmacol 2013; 72:489-90. [PMID: 23779068 DOI: 10.1007/s00280-013-2213-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 06/10/2013] [Indexed: 12/13/2022]
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Modjtahedi BS, Maibach H, Park S. Multifocal bilateral choroidal neovascularization in a patient on ipilimumab for metastatic melanoma. Cutan Ocul Toxicol 2013; 32:341-3. [DOI: 10.3109/15569527.2013.781618] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tarhini A. Immune-mediated adverse events associated with ipilimumab ctla-4 blockade therapy: the underlying mechanisms and clinical management. SCIENTIFICA 2013; 2013:857519. [PMID: 24278787 PMCID: PMC3820355 DOI: 10.1155/2013/857519] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/10/2013] [Indexed: 06/02/2023]
Abstract
Immunomodulation with the anti-CTLA-4 monoclonal antibody ipilimumab has been shown to extend overall survival (OS) in previously treated and treatment-naive patients with unresectable stage III or IV melanoma. Blockade of CTLA-4 signaling with ipilimumab prolongs T-cell activation and restores T-cell proliferation, thus amplifying T-cell-mediated immunity and the patient's capacity to mount an effective antitumor immune response. While this immunostimulation has unprecedented OS benefits in the melanoma setting, it can also result in immune-mediated effects on various organ systems, leading to immune-related adverse events (irAEs). Ipilimumab-associated irAEs are common and typically low grade and manageable, but can also be serious and life threatening. The skin and gastrointestinal tract are most frequently affected, while hepatic, endocrine, and neurologic events are less common. With proper management, most irAEs resolve within a relatively short time, with a predictable resolution pattern. Prompt and appropriate management of these irAEs is essential and treatment guidelines have been developed to assist oncologists and their teams. Implementation of these irAE management algorithms will help ensure that patients are able to benefit from ipilimumab therapy with adequate control of toxicities.
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Affiliation(s)
- Ahmad Tarhini
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh Cancer Institute, UPMC Cancer Pavilion, 5150 Centre Avenue, Room 555, Pittsburgh, PA 15232, USA
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Corsello SM, Barnabei A, Marchetti P, De Vecchis L, Salvatori R, Torino F. Endocrine side effects induced by immune checkpoint inhibitors. J Clin Endocrinol Metab 2013; 98:1361-75. [PMID: 23471977 DOI: 10.1210/jc.2012-4075] [Citation(s) in RCA: 309] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT In recent years, progress has been made in cancer immunotherapy by the development of drugs acting as modulators of immune checkpoint proteins, such as the cytotoxic T-lymphocyte antigen-4 (CTLA4) and programmed death-1 (PD-1), two co-inhibitory receptors that are expressed on T cells upon activation. These molecules play crucial roles in maintaining immune homeostasis by down-regulating T-cell signaling, thereby preventing unbridled T-cell proliferation while maintaining tolerance to self-antigens, such as tumor-associated antigens. CTLA4 blockade through systemic administration of the CTLA4-blocking antibody ipilimumab was shown to confer significant survival benefit and prolonged stable disease in patients affected by advanced cutaneous melanoma. Other immune checkpoint inhibitors are under clinical evaluation. However, immune checkpoint blockade can lead to the breaking of immune self-tolerance, thereby inducing a novel syndrome of autoimmune/autoinflammatory side effects, designated as "immune-related adverse events," mainly including rash, colitis, hepatitis, and endocrinopathies. DATA ACQUISITION We searched the medical literature using the words "hypophysitis," "hypopituitarism," "thyroid," "adrenal insufficiency," and "endocrine adverse events" in association with "immune checkpoint inhibitors," "ipilimumab," "tremelimumab," "PD-1," and "PD-1-L." EVIDENCE SYNTHESIS The spectrum of endocrine disease experienced by patients treated with ipilimumab includes most commonly hypophysitis, more rarely thyroid disease or abnormalities in thyroid function tests, and occasionally primary adrenal insufficiency. Hypophysitis has emerged as a distinctive side effect of CTLA4-blocking antibodies, establishing a new form of autoimmune pituitary disease. This condition, if not promptly recognized, may be life-threatening (due to secondary hypoadrenalism). Hypopituitarism caused by these agents is rarely reversible, and prolonged or lifelong substitutive hormonal treatment is often required. The precise mechanism of injury to the endocrine system triggered by these drugs is yet to be fully elucidated. CONCLUSIONS Although reports of endocrine side effects caused by cancer immune therapy are abundant, their exact prevalence and mechanism are unclear. Well-designed correlative studies oriented to finding and validating predictive factors of autoimmune toxicity are urgently needed.
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Voskens CJ, Goldinger SM, Loquai C, Robert C, Kaehler KC, Berking C, Bergmann T, Bockmeyer CL, Eigentler T, Fluck M, Garbe C, Gutzmer R, Grabbe S, Hauschild A, Hein R, Hundorfean G, Justich A, Keller U, Klein C, Mateus C, Mohr P, Paetzold S, Satzger I, Schadendorf D, Schlaeppi M, Schuler G, Schuler-Thurner B, Trefzer U, Ulrich J, Vaubel J, von Moos R, Weder P, Wilhelm T, Göppner D, Dummer R, Heinzerling LM. The price of tumor control: an analysis of rare side effects of anti-CTLA-4 therapy in metastatic melanoma from the ipilimumab network. PLoS One 2013; 8:e53745. [PMID: 23341990 PMCID: PMC3544906 DOI: 10.1371/journal.pone.0053745] [Citation(s) in RCA: 358] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 12/03/2012] [Indexed: 01/17/2023] Open
Abstract
Background Ipilimumab, a cytotoxic T-lymphocyte antigen-4 (CTLA-4) blocking antibody, has been approved for the treatment of metastatic melanoma and induces adverse events (AE) in up to 64% of patients. Treatment algorithms for the management of common ipilimumab-induced AEs have lead to a reduction of morbidity, e.g. due to bowel perforations. However, the spectrum of less common AEs is expanding as ipilimumab is increasingly applied. Stringent recognition and management of AEs will reduce drug-induced morbidity and costs, and thus, positively impact the cost-benefit ratio of the drug. To facilitate timely identification and adequate management data on rare AEs were analyzed at 19 skin cancer centers. Methods and Findings Patient files (n = 752) were screened for rare ipilimumab-associated AEs. A total of 120 AEs, some of which were life-threatening or even fatal, were reported and summarized by organ system describing the most instructive cases in detail. Previously unreported AEs like drug rash with eosinophilia and systemic symptoms (DRESS), granulomatous inflammation of the central nervous system, and aseptic meningitis, were documented. Obstacles included patientś delay in reporting symptoms and the differentiation of steroid-induced from ipilimumab-induced AEs under steroid treatment. Importantly, response rate was high in this patient population with tumor regression in 30.9% and a tumor control rate of 61.8% in stage IV melanoma patients despite the fact that some patients received only two of four recommended ipilimumab infusions. This suggests that ipilimumab-induced antitumor responses can have an early onset and that severe autoimmune reactions may reflect overtreatment. Conclusion The wide spectrum of ipilimumab-induced AEs demands doctor and patient awareness to reduce morbidity and treatment costs and true ipilimumab success is dictated by both objective tumor responses and controlling severe side effects.
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Affiliation(s)
| | | | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Caroline Robert
- Institute Gustave Roussy, Department of Dermatology, Villejuif, France
| | | | - Carola Berking
- Department of Dermatology and Allergology, University of Munich LMU, Munich, Germany
| | - Tanja Bergmann
- Department of Internal Medicine (Gastroenterology, Endocrinology, and Pneumology), University Hospital Erlangen, Erlangen, Germany
| | - Clemens L. Bockmeyer
- Department of Dermatology and Allergy/Department of Pathology, Skin Cancer Center Hannover/Hannover Medical School, Hannover, Germany
| | - Thomas Eigentler
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Michael Fluck
- Department of Dermatology, Hospital Hornheide, Münster, Germany
| | - Claus Garbe
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Ralf Gutzmer
- Department of Dermatology and Allergy/Department of Pathology, Skin Cancer Center Hannover/Hannover Medical School, Hannover, Germany
| | - Stephan Grabbe
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Axel Hauschild
- Department of Dermatology, University Hospital Kiel, Kiel, Germany
| | - Rüdiger Hein
- Department of Dermatology/III. Medical Department, Technische Universität München, München, Germany
| | - Gheorghe Hundorfean
- Department of Internal Medicine (Gastroenterology, Endocrinology, and Pneumology), University Hospital Erlangen, Erlangen, Germany
| | - Armin Justich
- Department of Dermatology, University Hospital Graz, Graz, Austria
| | - Ullrich Keller
- Department of Dermatology/III. Medical Department, Technische Universität München, München, Germany
| | - Christina Klein
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Christine Mateus
- Institute Gustave Roussy, Department of Dermatology, Villejuif, France
| | - Peter Mohr
- Department of Dermatology, Elbe Kliniken Buxtehude, Buxtehude, Germany
| | - Sylvie Paetzold
- Department of Dermatology, University Hospital Frankfurt, Frankfurt, Germany
| | - Imke Satzger
- Department of Dermatology and Allergy/Department of Pathology, Skin Cancer Center Hannover/Hannover Medical School, Hannover, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Marc Schlaeppi
- Department of Oncology/Hematology and Dermatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Gerold Schuler
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | | | - Uwe Trefzer
- Department of Dermatology, University Hospital Charité Berlin, Berlin, Germany
| | - Jens Ulrich
- Department of Dermatology, Hospital Quedlinburg, Quedlinburg, Germany
| | - Julia Vaubel
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Roger von Moos
- Department of Dermatology, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Patrik Weder
- Department of Oncology/Hematology and Dermatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Tabea Wilhelm
- Department of Dermatology, University Hospital Charité Berlin, Berlin, Germany
| | - Daniela Göppner
- Department of Dermatology, University Hospital Magdeburg, Magdeburg, Germany
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Lucie M. Heinzerling
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
- Department of Oncology/Hematology and Dermatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- * E-mail:
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Renouf DJ, Velazquez-Martin JP, Simpson R, Siu LL, Bedard PL. Ocular Toxicity of Targeted Therapies. J Clin Oncol 2012; 30:3277-86. [DOI: 10.1200/jco.2011.41.5851] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Molecularly targeted agents are commonly used in oncology practice, and many new targeted agents are currently being tested in clinical trials. Although these agents are thought to be more specific and less toxic then traditional cytotoxic chemotherapy, they are associated with a variety of toxicities, including ocular toxicity. Many of the molecules targeted by anticancer agents are also expressed in ocular tissues. We reviewed the literature for described ocular toxicities associated with both approved and investigational molecularly targeted agents. Ocular toxicity has been described with numerous approved targeted agents and also seems to be associated with several classes of agents currently being tested in early-phase clinical trials. We discuss the proposed pathogenesis, monitoring guidelines, and management recommendations. It is important for oncologists to be aware of the potential for ocular toxicity, with prompt recognition of symptoms that require referral to an ophthalmologist. Ongoing collaboration between oncologists and ocular disease specialists is critical as the use of molecularly targeted agents continues to expand and novel targeted drug combinations are developed.
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Affiliation(s)
- Daniel J. Renouf
- All authors: University Health Network–Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Juan P. Velazquez-Martin
- All authors: University Health Network–Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Rand Simpson
- All authors: University Health Network–Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Lillian L. Siu
- All authors: University Health Network–Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Philippe L. Bedard
- All authors: University Health Network–Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
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Wang XY, Zuo D, Sarkar D, Fisher PB. Blockade of cytotoxic T-lymphocyte antigen-4 as a new therapeutic approach for advanced melanoma. Expert Opin Pharmacother 2011; 12:2695-706. [PMID: 22077831 PMCID: PMC3711751 DOI: 10.1517/14656566.2011.629187] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The incidence of melanoma continues to rise, and prognosis in patients with metastatic melanoma remains poor. The cytotoxic T-lymphocyte antigen-4 (CTLA-4) serves as one of the primary immune check points and downregulates T-cell activation pathways. Enhancing T-cell activation by antibody blockade of CTLA-4 provides a new approach to overcome tumor-induced immune tolerance. Recently, anti-CTLA-4 therapy demonstrated significant clinical benefits in patients with metastatic melanoma, which led to the approval of ipilimumab by the FDA in early 2011. AREAS COVERED The fundamental concepts underlying CTLA-4 blockade-potentiated immune activation are presented in this paper, along with the scientific rationale for and the preclinical evidence supporting CTLA-4-targeted cancer immunotherapy. It also provides an update on clinical trials with anti-CTLA-4 inhibitors and discusses the associated autoimmune toxicity. EXPERT OPINION Given that overall survival is the only validated end point for anti-CTLA-4 therapy, the clinical implications of the antigen or tumor-specific immunity in patients remain to be clarified. Additional research is necessary to elucidate the prognostic significance of immune-related side effects and significantly optimize the treatment regimens. An improved understanding of the mechanisms of action of CTLA-4 antibodies may also culminate in wide-ranging clinical applications of this new therapy for other tumor types.
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Affiliation(s)
- Xiang-Yang Wang
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Institute of Molecular Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
| | - Daming Zuo
- Department of Immunology, Southern Medical University, Guangzhou, 510515, China
| | - Devanand Sarkar
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Institute of Molecular Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
| | - Paul B. Fisher
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Institute of Molecular Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
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