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Pisuchpen N, Durbin SM, Mooradian MJ, Fintelmann FJ, Reynolds KL, Dougan M, Kambadakone A. Multi-detector computed tomography (MDCT)-based severity score as a prognostic tool in patients with suspected immune checkpoint inhibitor therapy associated colitis. Eur Radiol 2021; 31:8868-8878. [PMID: 34081152 DOI: 10.1007/s00330-021-07925-7] [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: 11/13/2020] [Revised: 03/15/2021] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to assess MDCT as a diagnostic and prognostic tool in patients with suspected immune checkpoint inhibitor (ICI)-related colitis. MATERIALS AND METHODS This retrospective cohort study included patients receiving ICIs at three hospitals between 2015 and 2019 who underwent both abdominopelvic MDCT and endoscopic biopsy to workup suspected ICI-related colitis. Two radiologists independently reviewed MDCT images for signs of colitis based on pre-defined features. Diagnostic performance of MDCT was calculated and categorical variables between treatment subgroups were compared. Logistic regression was used to develop proposed MDCT criteria for diagnosis and MDCT severity score based on a combination of MDCT features of colitis to predict the patient outcomes in ICI-related colitis. RESULTS A total of 118 MDCT scans from 108 patients were evaluated for suspected colitis, with 72 confirmed ICI-related colitis cases. Sensitivity, specificity, PPV, and NPV of MDCT for diagnosis of ICI-related colitis was 81% (58/72), 52 % (24/46), 73% (58/80), and 63% (24/38), respectively. Small bowel involvement was visualized in 25% of cases with ICI-related colitis (18/72). In melanoma patients presenting with diarrhea grade ≥ 2 (n = 40), MDCT had the best diagnostic performance for ICI-related colitis (specificity = 80% [8/10], PPV = 92% [23/25]). MDCT severity scores predicted intravenous steroid use (OR 10.3, p = 0.004), length of stay > 7 days (OR 9.0, p < 0.001), and endoscopic mucosal ulceration (OR 4.7, p = 0.02). CONCLUSION MDCT is a useful diagnostic and prognostic tool for evaluating patients with immune checkpoint inhibitor-related colitis. An MDCT-based severity score enables assessment of disease severity and predicts outcome. KEY POINTS • MDCT is useful for the diagnosis of colitis in patients receiving immune checkpoint inhibitor (ICI) therapy, and an MDCT-based severity score allows for prognostication of patient outcomes. • MDCT yielded moderate sensitivity (81%) for diagnosis of ICI-related colitis but limited specificity (52%). However, in symptomatic melanoma patients (grade 2-4 diarrhea) with a high pretest probability, MDCT proved useful for diagnosis with a high PPV (92%). • For ICI-related colitis, our proposed MDCT severity score has prognostic value in predicting intravenous steroid use, prolonged length of stay during inpatient admission (> 7 days), and endoscopic mucosal ulceration.
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Affiliation(s)
- Nisanard Pisuchpen
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA.,Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Sienna M Durbin
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Meghan J Mooradian
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Florian J Fintelmann
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Avinash Kambadakone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA.
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Roosenboom B, Horjus Talabur Horje CS, Smids C, Leeuwis JW, van Koolwijk E, Groenen MJM, Wahab PJ, van Lochem EG. Distribution of mucosal PD-1 expressing T cells in patients with colitis of different etiologies. Scand J Gastroenterol 2021; 56:671-679. [PMID: 33779456 DOI: 10.1080/00365521.2021.1906316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Immunotherapy, targeting programmed death-1 (PD-1) enhances antitumor T-cell activity in patients with malignancies. Blocking PD-1 or its ligand may lead to fulminant colitis as serious adverse event in these patients. Since little is known of the presence and role of PD-1+T cells in colitis of different etiologies, we determined PD-1+T cells in mucosal specimens of patients with inflammatory bowel disease, infectious colitis (InfC), immunotherapy-related colitis (ImC) and healthy controls (HC). METHODS Newly diagnosed patients with ulcerative colitis (UC, n = 73), Crohn's disease (CD, n = 50), InfC (n = 5), ImC (n = 8) and HC (n = 8) were included. Baseline inflamed colonic biopsies were studied with immunohistochemistry and flowcytometry. RESULTS Using immunohistochemistry, PD-1 was not present on lymphocytes in the epithelium of all patients, nor in HC. The percentage PD-1+ of all lymphocytes in the lamina propria was 40% in UC, 5% in InfC, 3% in ImC and 0% in HC. Flowcytometry showed significant higher percentages of PD-1+T cells in inflamed biopsy specimens of UC patients (22%) compared to all other groups: CD patients (13%), InfC (12%), ImC (5%) and HC (6%). CONCLUSION There are relevant differences in distribution and frequencies of mucosal PD-1+ T-cell subsets in patients with UC, CD, InfC and ImC, supporting the hypothesis that these types of colitis are driven by different immunological pathways. The increased numbers of PD-1+ and PD-L1+ lymphocytes in the colonic mucosa of UC patients suggest that the PD-1/PD-L1 pathway might be more activated in UC than in CD.
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Affiliation(s)
- Britt Roosenboom
- Department of Gastroenterology and Hepatology, Rijnstate Crohn & Colitis Center, Rijnstate Hospital, Arnhem, The Netherlands
| | - Carmen S Horjus Talabur Horje
- Department of Gastroenterology and Hepatology, Rijnstate Crohn & Colitis Center, Rijnstate Hospital, Arnhem, The Netherlands
| | - Carolijn Smids
- Department of Gastroenterology and Hepatology, Rijnstate Crohn & Colitis Center, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Elly van Koolwijk
- Department of Microbiology and Immunology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Marcel J M Groenen
- Department of Gastroenterology and Hepatology, Rijnstate Crohn & Colitis Center, Rijnstate Hospital, Arnhem, The Netherlands
| | - Peter J Wahab
- Department of Gastroenterology and Hepatology, Rijnstate Crohn & Colitis Center, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ellen G van Lochem
- Department of Microbiology and Immunology, Rijnstate Hospital, Arnhem, The Netherlands
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53
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Zhang Q, Tang L, Zhou Y, He W, Li W. Immune Checkpoint Inhibitor-Associated Pneumonitis in Non-Small Cell Lung Cancer: Current Understanding in Characteristics, Diagnosis, and Management. Front Immunol 2021; 12:663986. [PMID: 34122422 PMCID: PMC8195248 DOI: 10.3389/fimmu.2021.663986] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/04/2021] [Indexed: 02/05/2023] Open
Abstract
Immunotherapy that includes programmed cell death-1 (PD-1), programmed cell death- ligand 1 (PD-L1) and cytotoxic T lymphocyte antigen 4 (CTLA-4) inhibitors has revolutionized the therapeutic strategy in multiple malignancies. Although it has achieved significant breakthrough in advanced non-small cell lung cancer patients, immune-related adverse events (irAEs) including checkpoint inhibitor pneumonitis (CIP), are widely reported. As the particularly worrisome and potentially lethal form of irAEs, CIP should be attached more importance. Especially in non-small cell lung cancer (NSCLC) patients, the features of CIP may be more complicated on account of the overlapping respiratory signs compromised by primary tumor following immunotherapy. Herein, we included the previous relevant reports and comprehensively summarized the characteristics, diagnosis, and management of CIP. We also discussed the future direction of optimal steroid therapeutic schedule for patients with CIP in NSCLC based on the current evidence.
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Affiliation(s)
- Qin Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.,Department of Postgraduate Student, West China Hospital, Sichuan University, Chengdu, China
| | - Liansha Tang
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yuwen Zhou
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenbo He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weimin Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
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54
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Zhang ML, Deshpande V. Histopathology of Gastrointestinal Immune-related Adverse Events: A Practical Review for the Practicing Pathologist. Am J Surg Pathol 2021; 46:e15-e26. [PMID: 33999556 DOI: 10.1097/pas.0000000000001730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Immune checkpoint inhibitors target checkpoint proteins with the goal of reinvigorating the host immune system and thus restoring antitumor response. With the dramatic increase in the use of checkpoint inhibitors for cancer treatment, surgical pathologists have assumed a major role in predicting the therapeutic efficacy (score based on programmed cell death ligand 1 immunohistochemistry and mismatch repair protein loss) as well as diagnosing the complications associated with these medications. Immune-related adverse events (irAEs) manifest as histologic changes seen in both the upper and lower gastrointestinal tract, and when viewed in isolation, may be morphologically indistinguishable from a wide range of diseases including infections, celiac disease, and inflammatory bowel disease, among others. Evaluation of biopsies from both the upper and lower gastrointestinal tract can aid in the distinction of gastrointestinal irAEs from their mimics. In the liver, the histologic changes of hepatic irAEs overlap with de novo diseases associated with hepatitic and cholangitic patterns of injury. The diagnosis of irAEs requires communication and collaboration from the pathologist, oncologist, and gastroenterologist. This review provides a background framework and illustrates the histologic features and differential diagnosis of gastrointestinal and hepatic irAEs.
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Affiliation(s)
- M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital Harvard Medical School, Boston, MA
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55
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Chhabra N, Kennedy J. A Review of Cancer Immunotherapy Toxicity: Immune Checkpoint Inhibitors. J Med Toxicol 2021; 17:411-424. [PMID: 33826117 DOI: 10.1007/s13181-021-00833-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 02/07/2023] Open
Abstract
Cancer immunotherapy, which leverages features of the immune system to target neoplastic cells, has revolutionized the treatment of cancer. The use of these therapies has rapidly expanded in the past two decades. Immune checkpoint inhibitors represent one drug class within immunotherapy with its first agent FDA-approved in 2011. Immune checkpoint inhibitors act by disrupting inhibitory signals from neoplastic cells to immune effector cells, allowing activated T-cells to target these neoplastic cells. Unique adverse effects associated with immune checkpoint inhibitors are termed immune-related adverse effects (irAEs) and are usually immunostimulatory in nature. Almost all organ systems may be affected by irAEs including the dermatologic, gastrointestinal, pulmonary, endocrine, and cardiovascular systems. These effects range from mild to life-threatening, and their onset can be delayed several weeks or months. For mild irAEs, symptomatic care is usually sufficient. For higher grade irAEs, discontinuation of therapy and initiation of immunosuppressive therapy may be necessary. The management of patients with irAEs involves multidisciplinary care coordination with respect to the long-term goals the individual patient. Clinicians must be aware of the unique and sometimes fatal toxicologic profiles associated with immunotherapies to ensure prompt diagnosis and appropriate management.
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Affiliation(s)
- Neeraj Chhabra
- Cook County Health, Department of Emergency Medicine, Division of Medical Toxicology, 1950 W Polk Street, 7th Floor, Chicago, IL, 60612, USA. .,Toxikon Consortium, Chicago, IL, USA.
| | - Joseph Kennedy
- Cook County Health, Department of Emergency Medicine, Division of Medical Toxicology, 1950 W Polk Street, 7th Floor, Chicago, IL, 60612, USA.,Toxikon Consortium, Chicago, IL, USA
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56
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Walsh MJ, Dougan M. Checkpoint blockade toxicities: Insights into autoimmunity and treatment. Semin Immunol 2021; 52:101473. [PMID: 33726931 DOI: 10.1016/j.smim.2021.101473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023]
Abstract
Checkpoint blockade has transformed not only the way cancers are treated, but also highlighted the importance of mounting a proper immune response against tumors. Despite advances in the field of immunotherapy, many patients develop a range of inflammatory toxicities that limit the efficacy of these therapies. These toxicities range from barrier site injury, such as colitis, to endocrine organ dysfunction, such as diabetes. In order to properly treat patients with cancer and avoid checkpoint blockade induced toxicities, we must gain a deeper understanding of the underlying mechanisms generating these adverse events. Cytotoxic and tissue-resident T cells likely play an important role in mediating some toxicities, though high levels of cytokines and the generation of auto-antibodies in other toxicities demonstrates these mechanisms are not all shared. Certain risk factors for specific toxicities may be able to predict who might benefit most from alternative therapies given the risk-benefit associated with checkpoint blockade. As the targets of checkpoint inhibitors have important functions in the prevention of autoimmunity, insights into risk factors and causes of toxicities will further our knowledge of fundamental immunology and enable the development of novel therapeutics.
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Affiliation(s)
- Michael J Walsh
- Department of Microbiology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA; Harvard Program in Virology, MA, USA; Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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57
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Dougan M, Luoma AM, Dougan SK, Wucherpfennig KW. Understanding and treating the inflammatory adverse events of cancer immunotherapy. Cell 2021; 184:1575-1588. [PMID: 33675691 DOI: 10.1016/j.cell.2021.02.011] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/31/2020] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
During the past decade, immunotherapies have made a major impact on the treatment of diverse types of cancer. Inflammatory toxicities are not only a major concern for Food and Drug Administration (FDA)-approved checkpoint blockade and chimeric antigen receptor (CAR) T cell therapies, but also limit the development and use of combination therapies. Fundamentally, these adverse events highlight the intricate balance of pro- and anti-inflammatory pathways that regulate protective immune responses. Here, we discuss the cellular and molecular mechanisms of inflammatory adverse events, current approaches to treatment, as well as opportunities for the design of immunotherapies that limit such inflammatory toxicities while preserving anti-tumor efficacy.
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Affiliation(s)
- Michael Dougan
- Division of Gastroenterology and Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02114, USA.
| | - Adrienne M Luoma
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Immunology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Stephanie K Dougan
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Immunology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Kai W Wucherpfennig
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Immunology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Department of Neurology, Brigham & Women's Hospital and Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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58
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Simó-Perdigó M, Vercher-Conejero JL, Viteri S, García-Velloso MJ. Immunotherapy, cancer and PET. Rev Esp Med Nucl Imagen Mol 2021; 40:123-135. [PMID: 33674234 DOI: 10.1016/j.remn.2021.02.001] [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: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
The treatment of cancer by immunotherapy has been a revolution, as it is the first strategy that manages to control the disease for prolonged periods of time. Its efficacy is associated with different imaging response patterns and the appearance of new toxicities. We would highlight two patterns of tumour response: pseudoprogression, or growth of tumour lesions after the start of immunotherapy treatment, followed by a significant reduction in lesions, and hyperprogression, acceleration of tumour progression and metastasis early after the start of treatment. The emergence of such patterns has generated new metabolic response criteria, such as PECRIT, PERCIMT, imPERCIST and IPERCIST. Of particular interest are the new immunoPET-specific biomarkers, as they allow the identification of patients presenting the tumour target and are useful for predicting response to immunotherapy.
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Affiliation(s)
- M Simó-Perdigó
- Servicio de Medicina Nuclear, Hospital Universitario Vall de Hebrón, Barcelona, España; Grupo de Oncología de la SEMNIM.
| | - J L Vercher-Conejero
- Servicio de Medicina Nuclear, Unidad PET, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, España; Grupo de Oncología de la SEMNIM
| | - S Viteri
- Instituto Oncológico Dr. Rosell, CM Teknon, Grupo QuironSalud, Barcelona, España; Grupo de Oncología de la SEMNIM
| | - M J García-Velloso
- Servicio de Medicina Nuclear, Clínica Universidad de Navarra, Pamplona, España; Grupo de Oncología de la SEMNIM
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59
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Simó-Perdigó M, Vercher-Conejero J, Viteri S, García-Velloso M. Immunotherapy, cancer and PET. Rev Esp Med Nucl Imagen Mol 2021. [DOI: 10.1016/j.remnie.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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60
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Ascierto PA, Butterfield LH, Campbell K, Daniele B, Dougan M, Emens LA, Formenti S, Janku F, Khleif SN, Kirchhoff T, Morabito A, Najjar Y, Nathan P, Odunsi K, Patnaik A, Paulos CM, Reinfeld BI, Skinner HD, Timmerman J, Puzanov I. Perspectives in immunotherapy: meeting report from the "Immunotherapy Bridge" (December 4th-5th, 2019, Naples, Italy). J Transl Med 2021; 19:13. [PMID: 33407605 PMCID: PMC7789268 DOI: 10.1186/s12967-020-02627-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/20/2020] [Indexed: 12/30/2022] Open
Abstract
Over the last few years, numerous clinical trials and real-world experience have provided a large amount of evidence demonstrating the potential for long-term survival with immunotherapy agents across various malignancies, beginning with melanoma and extending to other tumours. The clinical success of immune checkpoint blockade has encouraged increasing development of other immunotherapies. It has been estimated that there are over 3000 immuno-oncology trials ongoing, targeting hundreds of disease and immune pathways. Evolving topics on cancer immunotherapy, including the state of the art of immunotherapy across various malignancies, were the focus of discussions at the Immunotherapy Bridge meeting (4-5 December, 2019, Naples, Italy), and are summarised in this report.
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Affiliation(s)
- Paolo A Ascierto
- Cancer Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Cancer Immunotherapy and Innovative Therapy, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Via Mariano Semmola, 80131, Naples, Italy.
| | - Lisa H Butterfield
- PICI Research & Development, Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA
| | - Katie Campbell
- PICI Research & Development, Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA
| | | | - Michael Dougan
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Leisha A Emens
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Silvia Formenti
- Sandra and Edward Meyer Cancer Center, Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Filip Janku
- Division of Cancer Medicine, Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samir N Khleif
- The Loop Immuno-Oncology Research Laboratory, Lombardi Cancer Center, Georgetown University, Washington, DC, USA
| | - Tomas Kirchhoff
- Perlmutter Cancer Center, New York University School of Medicine, New York, NY, USA
| | - Alessandro Morabito
- Thoracic Medical Oncology, National Cancer Institute, IRCCS-Fondazione G. Pascale, Naples, Italy
| | - Yana Najjar
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Kunle Odunsi
- Center for Immunotherapy and Department of Gynecologic Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Akash Patnaik
- Section of Hematology and Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | | | - Heath D Skinner
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Timmerman
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Igor Puzanov
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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Pinter M, Scheiner B, Peck-Radosavljevic M. Immunotherapy for advanced hepatocellular carcinoma: a focus on special subgroups. Gut 2021; 70:204-214. [PMID: 32747413 PMCID: PMC7788203 DOI: 10.1136/gutjnl-2020-321702] [Citation(s) in RCA: 145] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/27/2020] [Accepted: 06/13/2020] [Indexed: 02/06/2023]
Abstract
Following the success of immune checkpoint blockers (ICBs) in different cancer types, a large number of studies are currently investigating ICBs in patients with hepatocellular carcinoma (HCC), alone or in combination with other treatments. Both nivolumab and pembrolizumab, as well as the combination of nivolumab plus ipilimumab have been granted accelerated approval by the United States Food and Drug Administration for sorafenib-pretreated patients. While nivolumab and pembrolizumab both failed to meet their primary endpoints in phase III trials, the combination of atezolizumab plus bevacizumab eventually improved overall and progression-free survival compared with sorafenib in a front-line phase III trial, and thus, will become the new standard of care in this setting. Despite this breakthrough, there are patient populations with certain underlying conditions that may not be ideal candidates for this new treatment either due to safety concerns or potential lack of efficacy. In this review, we discuss the safety of ICBs in patients with pre-existing autoimmune disease, IBD or a history of solid organ transplantation. Moreover, we summarise emerging preclinical and clinical data suggesting that ICBs may be less efficacious in patients with underlying non-alcoholic steatohepatitis or HCCs with activated Wnt/β-catenin signalling.
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Affiliation(s)
- Matthias Pinter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria .,Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria,Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology and Nephrology including Centralized Emergency Department (ZAE), Klinikum Klagenfurt am Worthersee, Klagenfurt, Kärnten, Austria
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Shroff GS, Shroff S, Ahuja J, Truong MT, Vlahos I. Imaging spectrum of adverse events of immune checkpoint inhibitors. Clin Radiol 2020; 76:262-272. [PMID: 33375984 DOI: 10.1016/j.crad.2020.11.117] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/20/2020] [Indexed: 12/16/2022]
Abstract
Immune checkpoint inhibitors (ICIs), a form of immunotherapy, are increasingly used for a variety of malignancies and have been linked to numerous treatment-related side effects known as immune-related adverse events (irAEs). IrAEs can affect multiple organ systems and are important to recognise in order to avoid misinterpretation as progressive tumour and to ensure appropriate management. In this pictorial review, we will briefly discuss radiological response criteria of immunotherapy and describe the imaging appearances of the wide spectrum of these ICI-associated toxicities.
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Affiliation(s)
- G S Shroff
- MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1478, Houston, TX, 77030, USA.
| | - S Shroff
- Houston Methodist, 6560 Fannin St. Ste 802, Houston, TX, 77030, USA
| | - J Ahuja
- MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1478, Houston, TX, 77030, USA
| | - M T Truong
- MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1478, Houston, TX, 77030, USA
| | - I Vlahos
- MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1478, Houston, TX, 77030, USA
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63
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Deng W, Wang Y, Liu X, Liu J, Wang L, Yang Z, Yang M, An Y, Tang C, Sanford NN, Kim BYS, Jiang W. Assessment of Trends in Second Primary Cancers in Patients With Metastatic Melanoma From 2005 to 2016. JAMA Netw Open 2020; 3:e2028627. [PMID: 33295975 PMCID: PMC7726633 DOI: 10.1001/jamanetworkopen.2020.28627] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE To date, the risk of developing second primary cancers (SPCs) after the first primary melanoma has not been studied in the era of immune checkpoint inhibitors (ICIs). OBJECTIVE To assess differences in the risk of SPCs in patients with primary melanoma before (2005-2010) and after (2011-2016) the introduction and approval of ICIs. DESIGN, SETTING, AND PARTICIPANTS Population-based cohort study using the Surveillance, Epidemiology, and End Results database from January 2005 to December 2016 of patients diagnosed with metastatic melanoma. Data were analyzed from January 4 to June 30, 2020. EXPOSURES Receipt of immunotherapy or other anticancer agents. MAIN OUTCOMES AND MEASURES The primary outcome was the development of second primary cancers in patients with melanoma. Standardized incidence ratios (SIRs) were calculated for the development of SPCs before and after the introduction of ICIs. RESULTS Among 5016 patients with diagnosed metastatic melanoma, 2888 (58%) were younger than 65 years at the time of diagnosis, and 3441 (69%) were male. From 2005 to 2010, SIRs were 3.24 (95% CI, 0.08-18.04) for small intestine cancer, 1.93 (95% CI, 1.14-3.05) for lung and bronchus cancer, 2.77 (95% CI, 1.02-6.03) for kidney cancer, and 7.29 (95% CI, 2.93-15.02) for myeloma. From 2011 to 2016, SIRs were 9.23 (95% CI, 1.12-33.35) for small intestine cancer, 1.54 (95% CI, 0.71-2.93) for lung and bronchus cancer, 2.66 (95% CI, 0.73-6.82) for kidney cancer, and 5.90 (95% CI, 1.61-15.10) for myeloma. The overall risk of developing SPCs in individuals who survived the first primary melanoma was 65% higher (SIR, 1.65; 95% CI, 1.35-2.00) in the pre-ICIs period and 98% higher (SIR, 1.98; 95% CI, 1.57-2.45) in the post-ICIs period than the overall cancer incidence rate in the general population. CONCLUSIONS AND RELEVANCE In this study, an increase in the overall risk of second primary cancers after melanoma after the introduction of immune checkpoint inhibitors was observed. The pattern of SPCs has been altered in the era of systemic therapy. Close monitoring and screening for SPCs may be warranted in patients with metastatic melanoma.
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Affiliation(s)
- Weiye Deng
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Yifan Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Xiangyu Liu
- Department of Biostatistics and Data Science, School of Public Health, the University of Texas Health Science Center, Houston
| | - Jieqiong Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liang Wang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Zhaogang Yang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Mingming Yang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Yi An
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Chad Tang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Nina N. Sanford
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Betty Y. S. Kim
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston
| | - Wen Jiang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
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Immune manifestations with checkpoint inhibitors in a single Brazilian center: experience and literature review. Future Sci OA 2020; 7:FSO655. [PMID: 33437507 PMCID: PMC7787148 DOI: 10.2144/fsoa-2020-0129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives The presence of autoimmune events were recorded in patients receiving immune checkpoint inhibitors. Materials & Methods Retrospective study in patients receiving immune checkpoint inhibitors (ICIs) during the period of 2012-2019. Results A total of 554 patients received ICIs of which 123 developed an immune related adverse event. Twenty one (17%) with toxicity were identified as having a pre-existing autoimmune disease and 88 required treatment with corticosteroids or hormone replacement. Thirty two (26%) out of 123 had to temporarily discontinue ICIs due to autoimmune manifestations. Endocrine and skin manifestations were the most prevalent immune disorders in our cohort. In melanoma better efficacy was seen in patients with immune toxicity. Conclusion Autoimmune diseases appear in patients receiving ICIs in this real world experience. Our results differ from other series on the frequency of autoimmunity. Complete discontinuation of ICIs due to autoimmunity was rare.
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65
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Li L, Yang Z, Chen X. Recent Advances in Stimuli-Responsive Platforms for Cancer Immunotherapy. Acc Chem Res 2020; 53:2044-2054. [PMID: 32877161 DOI: 10.1021/acs.accounts.0c00334] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Immunotherapy has attracted significant interest because of its tremendous potential in cancer therapy. The recent advances in the identification of cancer-associated neoantigens, chimeric antigen receptor (CAR) T-cell and immune checkpoint blockade (ICB), have revolutionized the field of cancer immunotherapy. Cancer immunotherapeutic agents typically exhibit strong immune activation or inhibition activity, thereby inducing robust biological effect even when administered at a small dosage. However, in most cases, cancer immunotherapeutic targets are not cancer specific. Some of them are also expressed in nonmalignant normal tissues and the undesired release of the cancer immunotherapeutic agents into these normal tissues may lead to severe side effects. Thus, the on-demand release of the cancer immunotherapeutic agents into the target site is critical to achieving efficient antitumor immune responses while minimizing the side effects.In this Account, we introduce the recent progress of our group and others on the development of stimuli-responsive platforms for cancer immunotherapy. Stimuli-responsive platforms have been constructed for on-demand release of payloads in a temporally and spatially controllable manner. First, we give a brief introduction to the endogenous and exogenous stimuli that are employed to trigger the release of cancer immunotherapeutic agents. The chemical design strategies to construct the specific stimuli-responsive delivery systems are highlighted. Moreover, the recently developed representative stimuli-responsive platforms for the delivery of immune checkpoint inhibitors, indoleamine 2,3-dioxygenase (IDO) inhibitors, stimulator of interferon genes (STING) agonists, and near-infrared photoimmunotherapy (NIR-PIT) agents are discussed in detail. Meanwhile, we summarize the general chemical design for constructing stimuli-responsive delivery platforms targeting immune targets at distinct locations. Lastly, the probable issues on the clinical translation of these stimuli-responsive platforms for cancer immunotherapy are outlined. Since we are still on the way of exploring the immune system and optimizing the chemical design of biomaterials, we hope the information in this account can provide some valuable references for the development of optimal cancer immunotherapeutics.
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Affiliation(s)
- Ling Li
- Laboratory of Molecular Imaging and Nanomedicine (LOMIN), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Institutes of Health (NIH) Bethesda, Maryland 20892, United States
| | - Zhen Yang
- Laboratory of Molecular Imaging and Nanomedicine (LOMIN), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Institutes of Health (NIH) Bethesda, Maryland 20892, United States
| | - Xiaoyuan Chen
- Laboratory of Molecular Imaging and Nanomedicine (LOMIN), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Institutes of Health (NIH) Bethesda, Maryland 20892, United States
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66
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Abd El Aziz MA, Facciorusso A, Nayfeh T, Saadi S, Elnaggar M, Cotsoglou C, Sacco R. Immune Checkpoint Inhibitors for Unresectable Hepatocellular Carcinoma. Vaccines (Basel) 2020; 8:vaccines8040616. [PMID: 33086471 PMCID: PMC7712941 DOI: 10.3390/vaccines8040616] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022] Open
Abstract
Despite the advances in screening protocols and treatment options, hepatocellular carcinoma (HCC) is still considered to be the most lethal malignancy in patients with liver cirrhosis. Moreover, the survival outcomes after failure of first-line therapy for unresectable HCC is still poor with limited therapeutic options. One of these options is immune checkpoint inhibitors. The aim of this study is to comprehensively review the efficacy and safety of immune checkpoint inhibitors for patients with HCC.
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Affiliation(s)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, Ospedali Riuniti di Foggia, 71122 Foggia, Italy;
| | - Tarek Nayfeh
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA; (T.N.); (S.S.)
| | - Samer Saadi
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA; (T.N.); (S.S.)
| | - Mohamed Elnaggar
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Las Vegas, NV 1155, USA;
| | | | - Rodolfo Sacco
- Gastroenterology Unit, Department of Medical Sciences, Ospedali Riuniti di Foggia, 71122 Foggia, Italy;
- Gastroenterology Unit, Department of Medical Sciences, Ospedali Riuniti di Foggia, Viale Pinto, 1, 71100 Foggia, Italy
- Correspondence:
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Karami S, Sattarifard H, Kiumarsi M, Sarabandi S, Taheri M, Hashemi M, Bahari G, Ghavami S. Evaluating the Possible Association between PD-1 (Rs11568821, Rs2227981, Rs2227982) and PD-L1 (Rs4143815, Rs2890658) Polymorphisms and Susceptibility to Breast Cancer in a Sample of Southeast Iranian Women. Asian Pac J Cancer Prev 2020; 21:3115-3123. [PMID: 33112575 PMCID: PMC7798179 DOI: 10.31557/apjcp.2020.21.10.3115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Programmed cell death-1 (PD-1) and its ligands (PD-L1 and PD-L2) play a critical role as a regulator of immune-system cells, including T cell, natural killer T (NKT), monocytes, dendritic cells (DC), and B cells. OBJECTIVE This study aimed to find a possible association between PD-1 (rs11568821, rs2227981, rs2227982), and PD-L1 (rs4143815, rs2890658) variants and Breast Cancer (BC) risk in a sample of southeast Iranian women. METHOD The case-control study consisted of 520 individuals, including 260 histologically confirmed BC patients and 260 non-cancer age-matching healthy women as the control group. The Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) and Tetra-Primer Amplification Refractory Mutation System-Polymerase Chain Reaction (T-ARMS-PCR) methods were used for genotyping of PD-1 (rs11568821, rs2227981, rs2227982), and PD-L1 (rs4143815, rs2890658) polymorphisms. RESULTS AND CONCLUSION Our findings indicated that the PD-L1 rs4143815 (G/C) variant meaningfully reduced the risk of BC. However, the PD-L1 rs2890658 variant increased the BC risk in the AC genotype as well as the A allele. Furthermore, we could not find a meaningful association between PD-1 rs11568821, PD-1 rs2227981, PD-1 rs2227982, and BC. Our team examined the possible association between variants and clinicopathological characteristics, including age, size of tumour, lymph node, histology, grade of tumour, estrogen and progesterone receptors status as well as human growth factor receptor 2 (HER2). Our findings demonstrated that PD-L1 rs4143815, PD-L1 rs2890658, PD-1 rs2227982 had a significant association with age. Additionally, we found a significant relation between PD-1 rs2227982 variant and tumour size. Statistical analyzes of PD-1 rs2227981 and PD-1 rs11568821 variants showed a meaningful relation between tumour grade and tumour stage (p=0.006), respectively.<br />.
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Affiliation(s)
- Shima Karami
- Department of Clinical Biochemistry, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Hedieh Sattarifard
- Department of Clinical Biochemistry, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran.,Department of Human Anatomy and Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Mohammad Kiumarsi
- Department of Human Anatomy and Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Sahel Sarabandi
- Department of Clinical Biochemistry, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Mohsen Taheri
- Genetics of Non- Communicable Disease Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Mohammad Hashemi
- Department of Clinical Biochemistry, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Gholamreza Bahari
- Department of Clinical Biochemistry, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran.,Children and Adolescent Health Research Center, Resistant Tuberculosis Institute, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Saeid Ghavami
- Department of Human Anatomy and Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada.,Faculty of Medicine, Katowice School of Technology, 40-555 Katowice, Poland.,Autophagy Research Center, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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68
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Durbin SM, Mooradian MJ, Fintelmann FJ, Zubiri L, Chute DF, Kambadakone A, Pisuchpen N, Reynolds KL, Dougan M. Diagnostic utility of CT for suspected immune checkpoint inhibitor enterocolitis. J Immunother Cancer 2020; 8:e001329. [PMID: 33033184 PMCID: PMC7545618 DOI: 10.1136/jitc-2020-001329] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIMS Immune checkpoint inhibitor (ICI) enterocolitis is a common immune-related adverse event and can be fatal, especially when not diagnosed and treated promptly. The current gold standard for diagnosis is endoscopy with biopsy, but CT scan is a possible alternative. The primary objective of this study is to identify the diagnostic performance of CT in the evaluation of ICI enterocolitis. METHODS With institutional review board approval, we conducted a retrospective cohort study of patients who received ICI therapy between 2015 and 2019 across a healthcare system. Patients were included if they underwent both abdominal CT and endoscopy with biopsy within 3 days. The radiological and pathological diagnoses, as well as clinical characteristics, were extracted from the electronic medical record. We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CT for diagnosing ICI enterocolitis when compared with tissue diagnosis. RESULTS Of the 4474 patients screened, 138 met inclusion criteria. Most common tumor types were melanoma (37%) and lung cancer (19%). Seventy-four per cent were treated with antiprogrammed cell death (PD-1)/PD-L1 therapy. Thirty-nine per cent had signs of enterocolitis on CT scan and 58% had biopsy-proven ICI enterocolitis. Sensitivity and specificity of CT were 50% and 74%, respectively. PPV was 73% and NPV was 52%. Of those with confirmed ICI enterocolitis, 70% had grade 3 or higher symptoms, 91% received steroids and 40% received infliximab. CONCLUSION The performance of CT scan for diagnosis of ICI enterocolitis is moderate to poor and does not replace endoscopy with biopsy.
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Affiliation(s)
- Sienna M Durbin
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Meghan J Mooradian
- Harvard Medical School, Boston, Massachusetts, USA
- Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Florian Johannes Fintelmann
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leyre Zubiri
- Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donald F Chute
- Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Avinash Kambadakone
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nisanard Pisuchpen
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- The Thai Red Cross Society, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kerry L Reynolds
- Harvard Medical School, Boston, Massachusetts, USA
- Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael Dougan
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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69
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Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of severe gastrointestinal and hepatic toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6129-6143. [PMID: 32856210 DOI: 10.1007/s00520-020-05707-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Immune-related adverse events (IrAEs) affecting the gastrointestinal (GI) tract and liver are among the most frequent and most severe inflammatory toxicities from contemporary immunotherapy. Inflammation of the colon and or small intestines (entero)colitis is the single most common GI IrAE and is an important cause of delay of discontinuation of immunotherapy. The severity of these GI IrAEs can range from manageable with symptomatic treatment alone to life-threatening complications, including perforation and liver failure. The frequency and severity of GI IrAEs is dependent on the specific immunotherapy given, with cytotoxic T lymphocyte antigen (CTLA)-4 blockade more likely to induce severe GI IrAEs than blockade of either programmed cell death protein 1 (PD-1) or PD-1 ligand (PD-L1), and combination therapy showing the highest rate of GI IrAEs, particularly in the liver. To date, we have minimal prospective data on the appropriate diagnosis and management of GI IrAEs, and recommendations are based largely on retrospective data and expert opinion. Although clinical diagnoses of GI IrAEs are common, biopsy is the gold standard for diagnosis of both immunotherapy-induced enterocolitis and hepatitis and can play an important role in excluding competing, though less common, diagnoses and ensuring optimal management. GI IrAEs typically respond to high-dose corticosteroids, though a significant fraction of patients requires secondary immune suppression. For colitis, both TNF-α blockade with infliximab and integrin inhibition with vedolizumab have proved highly effective in corticosteroid-refractory cases. Detailed guidelines have been published for the management of low-grade GI IrAEs. In the setting of more severe toxicities, involvement of a GI specialist is generally recommended. The purpose of this review is to survey the available literature and provide management recommendations focused on the GI specialist.
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70
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Luoma AM, Suo S, Williams HL, Sharova T, Sullivan K, Manos M, Bowling P, Hodi FS, Rahma O, Sullivan RJ, Boland GM, Nowak JA, Dougan SK, Dougan M, Yuan GC, Wucherpfennig KW. Molecular Pathways of Colon Inflammation Induced by Cancer Immunotherapy. Cell 2020; 182:655-671.e22. [PMID: 32603654 DOI: 10.1016/j.cell.2020.06.001] [Citation(s) in RCA: 254] [Impact Index Per Article: 63.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/10/2020] [Accepted: 05/29/2020] [Indexed: 12/14/2022]
Abstract
Checkpoint blockade with antibodies specific for the PD-1 and CTLA-4 inhibitory receptors can induce durable responses in a wide range of human cancers. However, the immunological mechanisms responsible for severe inflammatory side effects remain poorly understood. Here we report a comprehensive single-cell analysis of immune cell populations in colitis, a common and severe side effect of checkpoint blockade. We observed a striking accumulation of CD8 T cells with highly cytotoxic and proliferative states and no evidence of regulatory T cell depletion. T cell receptor (TCR) sequence analysis demonstrated that a substantial fraction of colitis-associated CD8 T cells originated from tissue-resident populations, explaining the frequently early onset of colitis symptoms following treatment initiation. Our analysis also identified cytokines, chemokines, and surface receptors that could serve as therapeutic targets for colitis and potentially other inflammatory side effects of checkpoint blockade.
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Affiliation(s)
- Adrienne M Luoma
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Department of Immunology, Harvard Medical School, Boston, MA 02115, USA
| | - Shengbao Suo
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02215, USA
| | - Hannah L Williams
- Department of Medical Oncology, Dana-Farber Cancer Institute Boston, MA 02215, USA
| | - Tatyana Sharova
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA 02114, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Keri Sullivan
- Division of Gastroenterology and Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02114, USA
| | - Michael Manos
- Department of Medical Oncology, Dana-Farber Cancer Institute Boston, MA 02215, USA; Center for Immuno-oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Peter Bowling
- Department of Medical Oncology, Dana-Farber Cancer Institute Boston, MA 02215, USA; Center for Immuno-oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute Boston, MA 02215, USA; Center for Immuno-oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Osama Rahma
- Department of Medical Oncology, Dana-Farber Cancer Institute Boston, MA 02215, USA; Brigham and Women's Hospital and Dana-Farber/Harvard Cancer Center, Boston, MA, USA
| | - Ryan J Sullivan
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Genevieve M Boland
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA 02114, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jonathan A Nowak
- Department of Pathology, Brigham & Women's Hospital, Boston, MA 02115, USA
| | - Stephanie K Dougan
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Department of Immunology, Harvard Medical School, Boston, MA 02115, USA
| | - Michael Dougan
- Division of Gastroenterology and Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02114, USA.
| | - Guo-Cheng Yuan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02215, USA
| | - Kai W Wucherpfennig
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Department of Immunology, Harvard Medical School, Boston, MA 02115, USA; Department of Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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71
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Grover S, Dougan M, Tyan K, Giobbie-Hurder A, Blum SM, Ishizuka J, Qazi T, Elias R, Vora KB, Ruan AB, Martin-Doyle W, Manos M, Eastman L, Davis M, Gargano M, Haq R, Buchbinder EI, Sullivan RJ, Ott PA, Hodi FS, Rahma OE. Vitamin D intake is associated with decreased risk of immune checkpoint inhibitor-induced colitis. Cancer 2020; 126:3758-3767. [PMID: 32567084 DOI: 10.1002/cncr.32966] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is a lack of predictive markers informing on the risk of colitis in patients treated with immune checkpoint inhibitors (ICIs). The aim of this study was to identify potential factors associated with development of ICI colitis. METHODS We performed a retrospective analysis of melanoma patients at Dana-Farber Cancer Institute who received PD-1, CTLA-4, or combination ICIs between May 2011 to October 2017. Clinical and laboratory characteristics associated with pathologically confirmed ICI colitis were evaluated using multivariable logistic regression analyses. External confirmation was performed on an independent cohort from Massachusetts General Hospital. RESULTS The discovery cohort included 213 patients of whom 37 developed ICI colitis (17%). Vitamin D use was recorded in 66/213 patients (31%) before starting ICIs. In multivariable regression analysis, vitamin D use conferred significantly reduced odds of developing ICI colitis (OR 0.35, 95% CI 0.1-0.9). These results were also demonstrated in the confirmatory cohort (OR 0.46, 95% CI 0.2-0.9) of 169 patients of whom 49 developed ICI colitis (29%). Pre-treatment neutrophil-to-lymphocyte ratio (NLR) ≥5 predicted reduced odds of colitis (OR 0.34, 95% CI 0.1-0.9) only in the discovery cohort. CONCLUSIONS This is the first study to report that among patients treated with ICIs, vitamin D intake is associated with reduced risk for ICI colitis. This finding is consistent with prior reports of prophylactic use of vitamin D in ulcerative colitis and graft-versus-host-disease. This observation should be validated prospectively in future studies.
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Affiliation(s)
- Shilpa Grover
- Harvard Medical School, Boston, Massachusetts.,Division of Gastroenterology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Dougan
- Harvard Medical School, Boston, Massachusetts.,Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kevin Tyan
- Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anita Giobbie-Hurder
- Division of Biostatistics, Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Steven M Blum
- Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Broad Institute at MIT and Harvard, Cambridge, Massachusetts.,Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Jeffrey Ishizuka
- Departments of Medicine and Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Taha Qazi
- Division of Gastroenterology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rawad Elias
- Hartford HealthCare Cancer Institute, Hartford, Connecticut
| | | | - Alex B Ruan
- Harvard Medical School, Boston, Massachusetts
| | - William Martin-Doyle
- Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Manos
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lauren Eastman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Meredith Davis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Maria Gargano
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rizwan Haq
- Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth I Buchbinder
- Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ryan J Sullivan
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Patrick A Ott
- Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Broad Institute at MIT and Harvard, Cambridge, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - F Stephen Hodi
- Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Osama E Rahma
- Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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72
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Mooradian MJ, Wang DY, Coromilas A, Lumish M, Chen T, Giobbie-Hurder A, Johnson DB, Sullivan RJ, Dougan M. Mucosal inflammation predicts response to systemic steroids in immune checkpoint inhibitor colitis. J Immunother Cancer 2020; 8:jitc-2019-000451. [PMID: 32414860 PMCID: PMC7239692 DOI: 10.1136/jitc-2019-000451] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Immune-related colitis is a common, often serious complication of immune checkpoint inhibition (ICI). Although endoscopy is not strictly recommended for any grade of diarrhea/colitis, emerging evidence suggests that endoscopic evaluation may have important therapeutic implications. In this retrospective study, we sought to comprehensively characterize the clinical and histologic features of ICI-induced colitis with a specific focus on evaluating the prognostic role of endoscopy. METHODS Data were collected from the medical records of 130 patients with confirmed ICI-induced colitis. In a subset of patients (n=44) with endoscopic and pathologic data, endoscopic data were scored using the Mayo Endoscopic Score (MES) with scores ranging from 0 (no inflammation) to 3 (colonic ulceration). The impact of infliximab on antitumor outcomes was evaluated using progression-free survival (PFS) and overall survival (OS). RESULTS We identified 130 patients with ICI-induced colitis across two institutions. All patients were treated with corticosteroids. Additional and/or alternative immunosuppression was employed in 59 cases, with 52 patients (42%) requiring at least one infusion of infliximab 5 mg/kg. Endoscopic assessment with biopsy was performed in 123 cases of suspected colitis (95%), with 44 cases available for MES tabulation. Presence of ulceration (MES 3) was associated with use of infliximab (p=0.008) and MES was significantly higher in patients who received infliximab compared with those who did not (p=0.003) with a median score of 2.5; conversely, those with an MES of zero rarely required secondary immunosuppression. Notably, symptoms of colitis based on Common Terminology Criteria for Adverse Events grade had no association with endoscopic findings based on MES classification. After adjustment for baseline patient and disease characteristics, there was no significant difference in steroid duration or cancer-related outcomes in patients treated with infliximab. CONCLUSIONS In our study, we demonstrate the association of endoscopic features, specifically the MES, with immunosuppressive needs. Importantly, we also show that MES was not related to severity of patient symptoms. The data suggest that endoscopic features can guide clinical decision-making better than patient symptoms, both identifying high-risk patients who will require infliximab and those who are likely to respond to initial corticosteroids.
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Affiliation(s)
- Meghan J Mooradian
- Cancer
Center, Massachusetts General Hospital,
Boston, Massachusetts, USA,Department of
Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Y Wang
- Department of
Medicine, Vanderbilt University Medical Center,
Nashville, Tennessee, USA
| | | | - Melissa Lumish
- Department of
Medicine, Massachusetts General Hospital,
Boston, Massachusetts, USA
| | - Tianqi Chen
- Department of
Biostatistics and Computational Biology, Dana Farber Cancer
Institute, Boston, Massachusetts, USA
| | - Anita Giobbie-Hurder
- Department of
Biostatistics and Computational Biology, Dana Farber Cancer
Institute, Boston, Massachusetts, USA
| | - Douglas B. Johnson
- Department of
Medicine, Vanderbilt University Medical Center,
Nashville, Tennessee, USA
| | - Ryan J. Sullivan
- Cancer
Center, Massachusetts General Hospital,
Boston, Massachusetts, USA,Department of
Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Dougan
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA .,Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Grover S, Ruan AB, Srivoleti P, Giobbie-Hurder A, Braschi-Amirfarzan M, Srivastava A, Buchbinder EI, Ott PA, Kehl KL, Awad MM, Hodi FS, Rahma OE. Safety of Immune Checkpoint Inhibitors in Patients With Pre-Existing Inflammatory Bowel Disease and Microscopic Colitis. JCO Oncol Pract 2020; 16:e933-e942. [PMID: 32401685 DOI: 10.1200/jop.19.00672] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Enterocolitis is among the leading adverse events associated with immune checkpoint inhibitors (ICIs). There are limited retrospective data regarding the safety of ICIs in patients with inflammatory bowel disease (IBD; ulcerative colitis, Crohn's disease) because they have been generally excluded from clinical trials testing ICIs. Furthermore, there are no outcome data available in patients with microscopic colitis, a leading cause of chronic diarrhea. We aimed to study the safety of ICIs in patients with cancer with pre-existing IBD or microscopic colitis. METHODS We retrospectively reviewed the records of patients with cancer treated at our institution who received at least 1 dose of either a programmed cell death-1 (PD-1)/ PD-1 ligand inhibitor, cytotoxic T-lymphocyte-associated antigen 4 inhibitor, or both between 2011 and 2018. We identified patients with pre-existing IBD or microscopic colitis. RESULTS Of 548 patients with solid tumor treated with an ICI, we identified 25 with pre-existing colitis (21 IBD; 4 microscopic colitis). An enterocolitis flare occurred in 7 patients (28%): 3 of 4 patients (75%) with microscopic colitis and 4 of 21 (19%) with IBD. All were treated with systemic corticosteroids, 2 required an anti-tumor necrosis factor agent, and one required an anti-integrin agent and colectomy for treatment of refractory colitis. ICI therapy was discontinued in all patients who experienced an enterocolitis flare. CONCLUSION In our cohort, exacerbation of enterocolitis occurred in a notable percentage of patients with IBD and a majority of patients with microscopic colitis, leading to discontinuation of ICIs. Although these data suggest that patients with cancer with pre-existing IBD/microscopic colitis may be treated with ICIs, additional studies are needed to validate our results.
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Affiliation(s)
- Shilpa Grover
- Division of Gastroenterology, Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Alex B Ruan
- Division of Gastroenterology, Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Padmavathi Srivoleti
- Division of Gastroenterology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Anita Giobbie-Hurder
- Division of Biostatistics, Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Marta Braschi-Amirfarzan
- Harvard Medical School, Boston, MA.,Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Amitabh Srivastava
- Harvard Medical School, Boston, MA.,Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Elizabeth I Buchbinder
- Harvard Medical School, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Brookline, MA
| | - Patrick A Ott
- Harvard Medical School, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Brookline, MA
| | - Kenneth L Kehl
- Harvard Medical School, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Brookline, MA
| | - Mark M Awad
- Harvard Medical School, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Brookline, MA
| | - F Stephen Hodi
- Harvard Medical School, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Brookline, MA
| | - Osama E Rahma
- Harvard Medical School, Boston, MA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Brookline, MA
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74
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Liang J, Chen D, Chen L, She X, Zhang H, Xiao Y. The potentiality of immunotherapy for sarcomas: a summary of potential predictive biomarkers. Future Oncol 2020; 16:1211-1223. [PMID: 32396026 DOI: 10.2217/fon-2020-0118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Sarcomas are rare and heterogeneous malignant tumors of mesenchymal origin. A total of 25-50% of patients treated with initial curative intent will develop as recurrent and metastatic disease. In the recurrent and metastatic setting, effect of chemotherapy is limited; therefore, more effective therapies are urgently desired. As a brake for activation of T cell, PD-1/PD-L1 plays a crucial role in the progression of tumor by altering status of immune surveillance. Some success has been acquired recently in the use of PD-1/PD-L1 inhibitors for the treatment of several solid tumors, for examples, non-small-cell lung cancer and melanoma. Immunotherapeutic strategies based on PD-1/PD-L1 for sarcomas have also been explored these years. As in other cancers, major challenges are identification of biomarkers to predict response for immunotherapy, optimization of patient's benefit and minimization of side effects. Therefore, we focused on potential biomarkers of immunotherapy for treatment of sarcomas in this review.
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Affiliation(s)
- Jin Liang
- Department of Medical Oncology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan province 650032, PR China
| | - Dedian Chen
- Department of Breast Surgery, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan, Kunming, Yunnan 650118, PR China
| | - Liyao Chen
- Department of Radiotherapy, The First People's Hospital of Yuxi City. Yuxi, Yunnan province 653100, PR China
| | - Xueke She
- The Medical Department, 3D Medicines Inc., Shanghai, 201114, PR China
| | - Hushan Zhang
- The Medical Department, 3D Medicines Inc., Shanghai, 201114, PR China.,Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, PR China
| | - Yanbin Xiao
- Department of Orthopaedics, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan, Kunming, Yunnan province 650118, PR China
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Parthymos I, Liamis G, Dounousi E, Pentheroudakis G, Mauri D, Zarkavelis G, Florentin M. Metabolic consequences of immune checkpoint inhibitors: A new challenge in clinical practice. Crit Rev Oncol Hematol 2020; 151:102979. [PMID: 32480349 DOI: 10.1016/j.critrevonc.2020.102979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 02/29/2020] [Accepted: 05/03/2020] [Indexed: 12/13/2022] Open
Abstract
Treatment of oncologic patients has progressed greatly the last few years with the development of immune checkpoint inhibitors (ICPIs). These drugs are associated with the immune system and, thus, may cause side effects of immune origin, the so called immune related adverse events (irAEs). Immune related AEs may actually affect all organs and systems and frequently resemble clinical entities commonly encountered in clinical practice. As ICPIs have improved both quality of life and life expectancy, clinicians of various specialties may need to deal with irAEs in their everyday practice. Therefore, they should be able to recognize them timely and treat them accordingly. Herein, we review the pathophysiology, clinical manifestations and treatment of irAEs.
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Affiliation(s)
- Ioannis Parthymos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Evangelia Dounousi
- Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Pentheroudakis
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - Davide Mauri
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - George Zarkavelis
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - Matilda Florentin
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece.
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76
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Checkpoint inhibitors (CPI) and autoimmune chronic inflammatory diseases (ACIDs): tolerance and loss of tolerance in the occurrence of immuno-rheumatologic manifestations. Clin Immunol 2020; 214:108395. [DOI: 10.1016/j.clim.2020.108395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/18/2020] [Accepted: 03/25/2020] [Indexed: 12/15/2022]
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77
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Abu-Sbeih H, Wang Y. Management Considerations for Immune Checkpoint Inhibitor-Induced Enterocolitis Based on Management of Inflammatory Bowel Disease. Inflamm Bowel Dis 2020; 26:662-668. [PMID: 31560045 DOI: 10.1093/ibd/izz212] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Immune checkpoint inhibitor therapy has significantly improved the outcomes of various advanced malignancies that were deemed unruly prior to its invention. Immune-mediated diarrhea and enterocolitis are among the most frequently encountered adverse events of immune checkpoint inhibitor therapy. Given the increasing use of these therapies in the treatment of an ever-growing number of malignancies, providing appropriate treatment for such adverse effects has become crucial. METHODS In this review, we summarize the current body of evidence concerning the management of immune-mediated diarrhea and enterocolitis. Additionally, management of immune-mediated diarrhea and enterocolitis is likened to that of inflammatory bowel disease, given the resemblance between both entities in pathogenesis and clinical features. Reviewing the literature raised several points regarding this devastating toxicity that still need further investigation by future efforts. RESULTS Endoscopic and histologic evaluation is pivotal in the assessment of immune-mediated diarrhea and enterocolitis and provides vital information regarding the severity of the disease to guide treatment. Corticosteroids are the main therapy for immune-mediated diarrhea and enterocolitis, with infliximab and vedolizumab as second-line agents. Recently, fecal microbiota transplantation has emerged as a treatment option for immune-mediated diarrhea and enterocolitis that is refractory to corticosteroids. Restarting immune checkpoint inhibitor therapy after resolution of immune-mediated diarrhea and enterocolitis carries a risk of recurrence that is mostly controllable with current immune-suppressive treatment. CONCLUSIONS Lastly, we propose a management algorithm for immune-mediated diarrhea and enterocolitis. Prospective research, preferably as collaborative efforts from oncology and gastroenterology specialists, is needed to refine the management of immune-mediated diarrhea and enterocolitis.
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Affiliation(s)
- Hamzah Abu-Sbeih
- Department of Internal Medicine, The University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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78
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Darnell EP, Mooradian MJ, Baruch EN, Yilmaz M, Reynolds KL. Immune-Related Adverse Events (irAEs): Diagnosis, Management, and Clinical Pearls. Curr Oncol Rep 2020; 22:39. [PMID: 32200442 DOI: 10.1007/s11912-020-0897-9] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW While immune checkpoint inhibitor (ICI) therapy has improved melanoma patient outcomes, it has also resulted in the rise of unique immune-related adverse events (irAEs). Here, we review and synthesize irAE management recommendations from several oncological societies into a streamlined format to aid in diagnosis and management. We also include clinical pearls highlighting several recent research studies in this field. RECENT FINDINGS Knowledge of immunotherapy toxicity has continually evolved, and several major oncologic societies have recently released new or updated guidelines. Keeping up with the evolving field of immunotherapy and related toxicities is crucial, because ICI use, in combination with other agents, will only continue to increase and likely result in new and different patterns of irAEs. Providing clear and concise references for clinicians will help ensure proper irAE evaluation and management going forward. We present one such reference here, covering management of common and/or serious irAEs.
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Affiliation(s)
- Eli P Darnell
- Division of Internal Medicine, Bartlett, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - Meghan J Mooradian
- Division of Medical Oncology, Bartlett, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA.,Harvard Medical School, Boston, MA, USA
| | - Erez N Baruch
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel.,Department of Clinical Microbiology and Immunology, Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 39040, 6997801, Tel Aviv, Israel
| | | | - Kerry L Reynolds
- Division of Medical Oncology, Bartlett, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA. .,Harvard Medical School, Boston, MA, USA.
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79
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Dougan M. Gastrointestinal and Hepatic Complications of Immunotherapy: Current Management and Future Perspectives. Curr Gastroenterol Rep 2020; 22:15. [PMID: 32185493 DOI: 10.1007/s11894-020-0752-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Checkpoint inhibitor (CPI) immunotherapy has transformed the treatment of multiple cancers over the past decade, leading to durable remissions, but also to severe inflammatory toxicities. These toxicities, termed immune-related adverse events (irAEs), can affect any organ system in the body, but commonly induce inflammation in barrier organs. Gastrointestinal (GI) and hepatic irAEs are among the most frequent and most severe from contemporary immunotherapies, with inflammation in the colon and or small intestines (entero)colitis as the single most common GI irAE. The aim of this review is to describe the evidence supporting our current understanding of CPI enterocolitis and hepatitis, as well as the management of these entities. RECENT FINDINGS Although most patients who develop enterocolitis recover without long-term GI sequelae, enterocolitis is still an important reason for treatment discontinuation, which, in patients with metastatic cancer, can be a life-threatening outcome. At present, we have almost no prospective, randomized data regarding the management of CPI enterocolitis, and current management algorithms are based on expert opinion and small retrospective studies with a high likelihood of bias. Retrospective studies have defined colonic ulceration as a predictor of colitis responsiveness to corticosteroids, and have defined microscopic colitis as a subtype of CPI enterocolitis with a distinct treatment response. Corticosteroids appear to be effective for 60-70% of patients with CPI enterocolitis, with about a third of patients requiring escalation to a biologic agent such as infliximab or vedolizumab. Yet proper sequencing of these treatments to minimize risk and maximize treatment benefit has not been established, and we do not know how treatment of colitis influences cancer outcomes. CPI enterocolitis and hepatitis are important causes of treatment interruption and discontinue, and significant morbidity in patients undergoing immunotherapy. As guidelines for diagnosis and management rely heavily on expert opinion, we have an urgent need for randomized and prospective trials that use both colitis and cancer outcomes to determine optimal management strategies.
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Affiliation(s)
- Michael Dougan
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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80
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Economopoulou P, Nicolatou-Galitis O, Kotsantis I, Psyrri A. Nivolumab-related lichen planus of the lip in a patient with head and neck cancer. Oral Oncol 2020; 104:104623. [PMID: 32144002 DOI: 10.1016/j.oraloncology.2020.104623] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 10/24/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are among the most promising drugs in the field of immuno-oncology; they represent monoclonal antibodies that modulate the effects of immune checkpoints, such as Programmed Cell Death protein 1 (PD-1) which is a co-inhibitory signal responsible for immune suppression. Dermatologic immune-related toxicity is a common type of toxicity associated with these agents. However, oral skin reactions are rare. Herein, we describe an unusual case of a patient that developed oral lichen planus during treatment with anti-PD-1 inhibitor nivolumab.
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Affiliation(s)
- Panagiota Economopoulou
- Section of Medical Oncology, Second Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, 1st Rimini St, 12462 Haidari, Athens, Greece
| | - Ourania Nicolatou-Galitis
- Clinic of Hospital Dentistry, Dental School, University of Athens, 2nd Thivon St, 15127 Goudi, Athens, Greece
| | - Ioannis Kotsantis
- Section of Medical Oncology, Second Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, 1st Rimini St, 12462 Haidari, Athens, Greece
| | - Amanda Psyrri
- Section of Medical Oncology, Second Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, 1st Rimini St, 12462 Haidari, Athens, Greece.
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81
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Zubiri L, Allen IM, Taylor MS, Guidon AC, Chen ST, Schoenfeld SR, Neilan TG, Sise ME, Mooradian MJ, Rubin KM, Leaf RK, Parikh AR, Faje A, Gainor JF, Cohen JV, Fintelmann FJ, Kohler MJ, Dougan M, Reynolds KL. Immune-Related Adverse Events in the Setting of PD-1/L1 Inhibitor Combination Therapy. Oncologist 2020; 25:e398-e404. [PMID: 32162817 PMCID: PMC7066708 DOI: 10.1634/theoncologist.2018-0883] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 08/02/2019] [Indexed: 12/12/2022] Open
Abstract
In 2018, a multi‐disciplinary workshop was held at the Massachusetts General Hospital to discuss challenges in defining, diagnosing, and treating immune‐related adverse events (irAE), including those that occur in patients administered PD‐1/L1 inhibitor combination therapy. In this commentary, the workshop participants present a clinical case that illustrates the complexity of irAE diagnosis and management in a patient receiving PD‐1/L1 combination therapy, summarize the current state of PD‐1/L1 combination therapy, and discuss challenges and opportunities for the evaluation of irAEs as these combinations become more widely used to treat patients with cancer.
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Affiliation(s)
- Leyre Zubiri
- Massachusetts General HospitalBostonMassachusettsUSA
| | - Ian M. Allen
- Massachusetts General HospitalBostonMassachusettsUSA
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Abu-Sbeih H, Faleck DM, Ricciuti B, Mendelsohn RB, Naqash AR, Cohen JV, Sellers MC, Balaji A, Ben-Betzalel G, Hajir I, Zhang J, Awad MM, Leonardi GC, Johnson DB, Pinato DJ, Owen DH, Weiss SA, Lamberti G, Lythgoe MP, Manuzzi L, Arnold C, Qiao W, Naidoo J, Markel G, Powell N, Yeung SCJ, Sharon E, Dougan M, Wang Y. Immune Checkpoint Inhibitor Therapy in Patients With Preexisting Inflammatory Bowel Disease. J Clin Oncol 2020; 38:576-583. [PMID: 31800340 PMCID: PMC7030892 DOI: 10.1200/jco.19.01674] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The risk of immune checkpoint inhibitor therapy-related GI adverse events in patients with cancer and inflammatory bowel disease (IBD) has not been well described. We characterized GI adverse events in patients with underlying IBD who received immune checkpoint inhibitors. PATIENTS AND METHODS We performed a multicenter, retrospective study of patients with documented IBD who received immune checkpoint inhibitor therapy between January 2010 and February 2019. Backward selection and multivariate logistic regression were conducted to assess risk of GI adverse events. RESULTS Of the 102 included patients, 17 received therapy targeting cytotoxic T-lymphocyte antigen-4, and 85 received monotherapy targeting programmed cell death 1 or its ligand. Half of the patients had Crohn's disease, and half had ulcerative colitis. The median time from last active IBD episode to immunotherapy initiation was 5 years (interquartile range, 3-12 years). Forty-three patients were not receiving treatment of IBD. GI adverse events occurred in 42 patients (41%) after a median of 62 days (interquartile range, 33-123 days), a rate higher than that among similar patients without underlying IBD who were treated at centers participating in the study (11%; P < .001). GI events among patients with IBD included grade 3 or 4 diarrhea in 21 patients (21%). Four patients experienced colonic perforation, 2 of whom required surgery. No GI adverse event-related deaths were recorded. Anti-cytotoxic T-lymphocyte antigen-4 therapy was associated with increased risk of GI adverse events on univariable but not multivariable analysis (odds ratio, 3.19; 95% CI, 1.8 to 9.48; P = .037; and odds ratio, 4.72; 95% CI, 0.95 to 23.53; P = .058, respectively). CONCLUSION Preexisting IBD increases the risk of severe GI adverse events in patients treated with immune checkpoint inhibitors.
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Affiliation(s)
| | | | - Biagio Ricciuti
- Dana-Farber Cancer Institute, Boston, MA,University of Perugia, Perugia, Italy
| | | | | | - Justine V. Cohen
- Massachusetts General Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Maclean C. Sellers
- Massachusetts General Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | | | | | | | | | | | - Giulia C. Leonardi
- University of Perugia, Perugia, Italy,University of Catania, Catania, Italy
| | | | - David J. Pinato
- Imperial College London, Hammersmith Hospital Campus, London, United Kingdom
| | | | | | - Giuseppe Lamberti
- Policlinico di Sant'Orsola University Hospital, Bologna University, Bologna, Italy
| | - Mark P. Lythgoe
- Imperial College London, Hammersmith Hospital Campus, London, United Kingdom
| | - Lisa Manuzzi
- Policlinico di Sant'Orsola University Hospital, Bologna University, Bologna, Italy
| | | | - Wei Qiao
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Nick Powell
- Kings College London, London, United Kingdom
| | | | | | - Michael Dougan
- Massachusetts General Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Yinghong Wang
- The University of Texas MD Anderson Cancer Center, Houston, TX,Yinghong Wang, MD, PhD, Department of Gastroenterology, Hepatology, and Nutrition, Unit 1466, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030; e-mail:
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Dougan M, Pietropaolo M. Time to dissect the autoimmune etiology of cancer antibody immunotherapy. J Clin Invest 2020; 130:51-61. [PMID: 31895048 PMCID: PMC6934191 DOI: 10.1172/jci131194] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Immunotherapy has transformed the treatment landscape for a wide range of human cancers. Immune checkpoint inhibitors (ICIs), monoclonal antibodies that block the immune-regulatory "checkpoint" receptors CTLA-4, PD-1, or its ligand PD-L1, can produce durable responses in some patients. However, coupled with their success, these treatments commonly evoke a wide range of immune-related adverse events (irAEs) that can affect any organ system and can be treatment-limiting and life-threatening, such as diabetic ketoacidosis, which appears to be more frequent than initially described. The majority of irAEs from checkpoint blockade involve either barrier tissues (e.g., gastrointestinal mucosa or skin) or endocrine organs, although any organ system can be affected. Often, irAEs resemble spontaneous autoimmune diseases, such as inflammatory bowel disease, autoimmune thyroid disease, type 1 diabetes mellitus (T1D), and autoimmune pancreatitis. Yet whether similar molecular or pathologic mechanisms underlie these apparent autoimmune adverse events and classical autoimmune diseases is presently unknown. Interestingly, evidence links HLA alleles associated with high risk for autoimmune disease with ICI-induced T1D and colitis. Understanding the genetic risks and immunologic mechanisms driving ICI-mediated inflammatory toxicities may not only identify therapeutic targets useful for managing irAEs, but may also provide new insights into the pathoetiology and treatment of autoimmune diseases.
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Affiliation(s)
- Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Massimo Pietropaolo
- Diabetes Research Center, Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Schoenfeld SR, Aronow ME, Leaf RK, Dougan M, Reynolds KL. Diagnosis and Management of Rare Immune-Related Adverse Events. Oncologist 2020; 25:6-14. [PMID: 31694890 PMCID: PMC6964128 DOI: 10.1634/theoncologist.2019-0083] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/27/2019] [Indexed: 12/13/2022] Open
Abstract
Oncologic treatment is being revolutionized by a burgeoning number of immune checkpoint inhibitors (ICPis). To date, seven ICPis have received Food and Drug Administration approval, targeting cytotoxic T-lymphocyte antigen, programmed cell death, or programmed cell death ligand. Adverse events associated with checkpoint inhibition have been described in the literature. Guidelines exist for the most common of these, but as the use of ICPis becomes more common, the number of patients presenting with rare events will increase. This article reviews the diagnosis and management of rare ocular, hematological, luminal gastrointestinal, and rheumatological toxicities arising from ICPi treatment. KEY POINTS: As the use of immune checkpoint inhibitors (ICPis) becomes more common, the number of rare immune-related adverse events (irAEs) will increase. A high level of suspicion is required to identify and treat these toxicities. Although it can be difficult to definitively attribute rare irAEs to ICPis, a temporal and mechanistic relationship and the absence of other etiologies should make the treating physician suspicious for a rare irAE. Certain rare irAEs, such as celiac disease, do not require treatment with glucocorticoids. Thus, differentiating this irAE from other gastrointestinal irAEs has important implications for treatment.
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Affiliation(s)
- Sara R. Schoenfeld
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Mary E. Aronow
- Retina Service, Massachusetts Eye and Ear, Harvard Medical SchoolBostonMassachusettsUSA
| | - Rebecca Karp Leaf
- Division of Hematology, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Michael Dougan
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Kerry L. Reynolds
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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85
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Boardman DA, Levings MK. Cancer immunotherapies repurposed for use in autoimmunity. Nat Biomed Eng 2019; 3:259-263. [PMID: 30952977 DOI: 10.1038/s41551-019-0359-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Dominic A Boardman
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Megan K Levings
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada. .,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada. .,School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, Canada.
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86
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Martins F, Sofiya L, Sykiotis GP, Lamine F, Maillard M, Fraga M, Shabafrouz K, Ribi C, Cairoli A, Guex-Crosier Y, Kuntzer T, Michielin O, Peters S, Coukos G, Spertini F, Thompson JA, Obeid M. Adverse effects of immune-checkpoint inhibitors: epidemiology, management and surveillance. Nat Rev Clin Oncol 2019; 16:563-580. [PMID: 31092901 DOI: 10.1038/s41571-019-0218-0] [Citation(s) in RCA: 1175] [Impact Index Per Article: 235.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Immune-checkpoint inhibitors (ICIs), including anti-cytotoxic T lymphocyte antigen 4 (CTLA-4), anti-programmed cell death 1 (PD-1) and anti-programmed cell death 1 ligand 1 (PD-L1) antibodies, are arguably the most important development in cancer therapy over the past decade. The indications for these agents continue to expand across malignancies and disease settings, thus reshaping many of the previous standard-of-care approaches and bringing new hope to patients. One of the costs of these advances is the emergence of a new spectrum of immune-related adverse events (irAEs), which are often distinctly different from the classical chemotherapy-related toxicities. Owing to the growing use of ICIs in oncology, clinicians will increasingly be confronted with common but also rare irAEs; hence, awareness needs to be raised regarding the clinical presentation, diagnosis and management of these toxicities. In this Review, we provide an overview of the various types of irAEs that have emerged to date. We discuss the epidemiology of these events and their kinetics, risk factors, subtypes and pathophysiology, as well as new insights regarding screening and surveillance strategies. We also highlight the most important aspects of the management of irAEs.
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Affiliation(s)
- Filipe Martins
- Service et Laboratoire Central d'Hématologie, Département d'Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.,School of Life Sciences, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | | | - Gerasimos P Sykiotis
- Service d'Endocrinologie, Diabétologie et Métabolisme, CHUV, Lausanne, Switzerland
| | - Faiza Lamine
- Service d'Endocrinologie, Diabétologie et Métabolisme, CHUV, Lausanne, Switzerland
| | - Michel Maillard
- Service de Gastro-entérologie et Hépatologie, CHUV, Lausanne, Switzerland.,Crohn's and Colitis Center Lausanne, Lausanne, Switzerland
| | - Montserrat Fraga
- Service de Gastro-entérologie et Hépatologie, CHUV, Lausanne, Switzerland
| | | | - Camillo Ribi
- Service Immunologie et Allergie, CHUV, Lausanne, Switzerland
| | - Anne Cairoli
- Service et Laboratoire Central d'Hématologie, Département d'Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Yan Guex-Crosier
- Hôpital Ophtalmique Jules Gonin - Fondation Asile des Aveugles, CHUV, Lausanne, Switzerland
| | | | | | | | - Georges Coukos
- Département d'Oncologie, CHUV, Lausanne, Switzerland.,Ludwig Institute for Cancer Research, Epalinges, Switzerland
| | | | - John A Thompson
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,National Cancer Institute, NIH, Bethesda, MD, USA
| | - Michel Obeid
- Service Immunologie et Allergie, CHUV, Lausanne, Switzerland. .,Faculté de Médecine Pitié-Salpêtrière, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France. .,Centre d'Immunothérapie et de Vaccinologie, CHUV, Lausanne, Switzerland.
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87
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Wu M, Shen J. From Super-Enhancer Non-coding RNA to Immune Checkpoint: Frameworks to Functions. Front Oncol 2019; 9:1307. [PMID: 31824865 PMCID: PMC6883490 DOI: 10.3389/fonc.2019.01307] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022] Open
Abstract
Super-enhancers (SEs) are clusters of enhancers that play a key role in regulating genes that determine cell identity. Enhancer RNAs (eRNAs) are non-coding RNAs transcribed from enhancers that function to promote the enhancer's functions via multiple mechanisms, such as recruiting transcription factors to specific enhancers, promoting enhancer-promoter looping, directing chromatin accessibility, interacting with RNA polymerase II and facilitating histone acetylation. Understanding how super-enhancer RNAs (seRNAs) contribute to specific gene regulation has thus become an area of active interest. Immune checkpoint deregulation is one of the key characteristics of tumors and autoimmune diseases, and is also closely related to cell identity. Recent studies revealed a potential pathway for seRNA's involvement in regulating the expression of immune checkpoints. The present study reviews the current knowledge of eRNA function, immune checkpoint blockage mechanism, and its effect. In addition, for the first time, we explore the direct and indirect roles of seRNAs in regulating immune checkpoint expression in cancer and autoimmune diseases.
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Affiliation(s)
- Manqing Wu
- State Key Laboratory for Oncogenes and Related Genes, Key Laboratory of Gastroenterology & Hepatology, Division of Gastroenterology and Hepatology, Ministry of Health, School of Medicine, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Shen
- State Key Laboratory for Oncogenes and Related Genes, Key Laboratory of Gastroenterology & Hepatology, Division of Gastroenterology and Hepatology, Ministry of Health, School of Medicine, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
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88
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Abstract
PURPOSE OF REVIEW This review addresses our current knowledge of immune-mediated colitis (IMC) and offers a practical guide to its management. RECENT FINDINGS Due to the similarity in clinical, endoscopic, and histologic findings between IMC and inflammatory bowel disease (IBD), gastroenterologists have tailored their approach to IMC management to that of IBD. Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that augment the T-cell anti-tumor response of the immune system and have demonstrated their importance in the treatment of a wide range of malignancies. With the growing benefits of ICIs, there are immune-related adverse events (irAEs) that mirror many known autoimmune diseases. Diarrhea and IMC are the most common and severe irAEs noted. No standardized guidelines exist in the management of these irAEs.
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Affiliation(s)
- Tara Menon
- The Ohio State University Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Anita Afzali
- The Ohio State University Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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89
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Zhang ML, Neyaz A, Patil D, Chen J, Dougan M, Deshpande V. Immune-related adverse events in the gastrointestinal tract: diagnostic utility of upper gastrointestinal biopsies. Histopathology 2019; 76:233-243. [PMID: 31361907 DOI: 10.1111/his.13963] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/29/2019] [Indexed: 12/17/2022]
Abstract
AIMS Immune checkpoint inhibitors (ICIs) improve survival across a range of malignancies but are also associated with a spectrum of gastrointestinal (GI) immune-related adverse events (GI-irAEs). The aims of this study were to explore the diagnostic value of gastric and duodenal biopsies and to address considerations in the differential diagnosis. METHODS AND RESULTS We identified 39 patients who were treated with ICIs and had a subsequent upper GI biopsy. We recorded clinical data and endoscopic findings, and reviewed their gastric, duodenal and colonic biopsies. Twenty-one (54%) patients were treated with an anti-programmed cell death protein 1 (PD-1)/anti-programmed cell death ligand 1 antibody alone, and 17 (44%) patients were treated with a combination of anti-cytotoxic T-lymphocyte-associated protein-4 and anti-PD-1 antibodies. Thirty-two (82%) patients presented with diarrhoea. Gastric alterations included periglandular inflammation and granulomas, and duodenal changes included villous blunting, intraepithelial lymphocytosis, granulomas, and neutrophilic activity. We recognised four patterns of colonic injury: (i) acute self-limiting colitis; (ii) lymphocytic colitis; (iii) collagenous colitis; and (iv) apoptosis-only. Twenty-nine (74%) and 10 (26%) patients were diagnosed clinically as positive and negative for GI-irAEs, respectively. Gastric periglandular inflammation (P = 0.004) and an increased number of colonic lamina propria mononuclear cells (P = 0.04) correlated with the clinical diagnosis of a GI-irAE. Histological alterations associated with ICI injury were more often identified in upper GI biopsies (71%) than in colonic biopsies (65%). CONCLUSIONS The morphological spectrum of ICI-related GI disease is broad, and mimics a range of infectious and inflammatory diseases. Gastric periglandular inflammation represents one of the more characteristic histological features of GI-irAEs. The study underscores the importance of a comprehensive review of upper and lower GI biopsies for the diagnosis of GI-irAEs.
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Affiliation(s)
- M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Azfar Neyaz
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Deepa Patil
- Harvard Medical School, Boston, MA, USA.,Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan Chen
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, MA, USA.,Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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90
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Hughes MS, Molina GE, Chen ST, Zheng H, Deshpande V, Fadden R, Sullivan RJ, Dougan M. Budesonide treatment for microscopic colitis from immune checkpoint inhibitors. J Immunother Cancer 2019; 7:292. [PMID: 31699151 PMCID: PMC6839080 DOI: 10.1186/s40425-019-0756-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (CPIs) are effective against a variety of malignancies but can be limited by inflammatory toxicities such as enterocolitis. Enterocolitis is typically treated with systemically active glucocorticoids. Endoscopy can stratify patients by the severity of mucosal inflammation, including identifying patients with colitis in the absence of visible mucosal changes: microscopic colitis. Whether patients with CPI microscopic colitis could be managed differently from colitis with more severe mucosal involvement is unclear. The objective of this study was to describe outcomes in CPI microscopic colitis focusing on the response to first line treatment with budesonide. METHODS We evaluated data from a retrospective cohort from a single-center large academic hospital. The participants were all adult patients evaluated by endoscopy for suspected CPI enterocolitis between 3/2017 and 3/2019. The exposures were: Mayo Endoscopic Score (range 0-3). The subset was: oral budesonide, maximum dose 12 mg daily, administered minimum of 5 weeks. The main outcomes and measures were: Primary: time from first CPI exposure to first glucocorticoid use; use of systemic glucocorticoids; time from symptom onset to resolution; continuation of CPI therapy; number of additional CPI infusions received. Secondary: admissions for symptom control; novel irAE development; need for second-line immunosuppression; oncologic outcomes. RESULTS We identified 38 patients with biopsy confirmed CPI enterocolitis, 13 in the microscopic colitis cohort, and 25 in the non-microscopic colitis cohort. Budesonide use was higher in the microscopic colitis cohort (12/13 vs 3/25, p < 0.001), and systemic glucocorticoid use was higher in non-microscopic colitis (22/25 vs. 3/13, p < 0.001). Time from symptom onset to resolution did not differ. Microscopic colitis patients more frequently remained on CPI after developing (entero)colitis (76.9% vs 16.0%, p < 0.001). Microscopic colitis patients tolerating further CPI received, on average, 4.2 CPI infusions more than non-microscopic colitis patients tolerating CPI (5.8 vs 1.6, p = 0.03). Microscopic colitis was associated with increased time-to-treatment-failure (HR 0.30, 95% CI 0.14-0.66) and progression-free survival (HR 0.22, 95% CI 0.07-0.70). CONCLUSIONS Gastrointestinal mucosal inflammation without visible mucosal injury is a distinct, prevalent CPI enterocolitis subset that can be diagnosed by endoscopy. First-line budesonide appears effective in controlling "microscopic colitis" symptoms and prolonging immunotherapy duration. These findings present a compelling rationale for routine endoscopic evaluation of suspected CPI enterocolitis and suggest an alternative glucocorticoid-sparing treatment strategy for a subset of such patients.
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Affiliation(s)
- Michael S Hughes
- Harvard Medical School, Boston, MA, USA
- Present address: Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Steven T Chen
- Harvard Medical School, Boston, MA, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Riley Fadden
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, MA, USA.
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
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91
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Gao L, Yang X, Yi C, Zhu H. Adverse Events of Concurrent Immune Checkpoint Inhibitors and Antiangiogenic Agents: A Systematic Review. Front Pharmacol 2019; 10:1173. [PMID: 31680957 PMCID: PMC6812341 DOI: 10.3389/fphar.2019.01173] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 09/12/2019] [Indexed: 02/05/2023] Open
Abstract
Background: Immune checkpoint blockade has revolutionized the treatment of multiple malignancies. Currently, however, the effect is not universal, with objective response rates (ORR) of about 15–25%, and even lower for some cancers. Abnormal vasculature is a hallmark of most solid tumors and plays a role in immune evasion. Growing body of evidence suggests that vascular normalization and immune reprogramming could operate synergistic effect, resulting in an enhanced therapeutic efficacy. However, the benefit of antitumor efficacy must be weighed against the risk of added toxicity. In this systematic review, we summarize severe toxicity observed in such a kind of combination regimen. Methods: PubMed and Embase were searched for English references published up to May 31, 2019, with MeSH and keywords search terms of immune checkpoint inhibitors (ICIs) and antiangiogenic agents approved for using in solid tumors. Studies performing concomitant use of ICIs and antiangiogenic agents, and also reporting severe treatment-related adverse events (trAEs) (≥grade 3), were included for further analysis. Results: A total of 32 studies including a total of 2,324 participants were analyzed. Limited available data suggests that both antiangiogenic monoclonal antibodies (mAbs) and tyrosine kinase inhibitors (TKIs) show potential risk of increasing treatment-related toxicity when combined with ICIs. Overall, the total incidence of severe adverse events (AEs) associated with ICIs plus mAbs (44.5%) is lower than that of ICIs plus TKIs (60.1%). However, the trAEs observed in combination therapy are mostly consistent with the known safety profiles of corresponding monotherapy, and they seem to be largely related to antiangiogenic agents, rather than a true immune-related adverse event (irAE) predominantly due to ICIs. The majority of trAEs are intervened by holding ICI treatment and adding corticosteroids, as well as reducing dose or adjusting administration frequency of the antiangiogenic drugs. Conclusions: Concurrent use of ICIs and antiangiogenic agents shows potential treatment-related toxicity. Further research is required to compare the efficacy and safety of the combination regimen and corresponding monotherapy and identify predictive biomarkers, as well as explore dose, duration, and sequencing schedules of drugs.
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Affiliation(s)
- Ling Gao
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xi Yang
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Yi
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Zhu
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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92
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Abstract
Immune-targeted therapeutics are being used in cancer. Immune "checkpoint inhibition" provides promise for prolonged disease-free patient survival. Use of immune checkpoint inhibitors in cancer has coincided with the onset of immune-related adverse events (irAEs). irAEs are caused by a break in host self-tolerance, which can be deadly. Acute management of irAEs is complicated by difficulty making a prompt clinical diagnosis. The goal is to maximize anticancer benefit while minimizing irAE risk. We currently lack diagnostic tools to assess pretreatment irAE risk and facilitate diagnosis. Current immunologic understanding of irAEs is discussed with an emphasis on how patients with congenital syndromes of T-cell activation may inform this understanding. The prospects of improving diagnostics for and treatment of irAEs are discussed.
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Affiliation(s)
- Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, COX 201, MGH, 55 Fruit Street, Boston, MA 02114, USA; Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA.
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93
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Melanoma and autoimmunity: spontaneous regressions as a possible model for new therapeutic approaches. Melanoma Res 2019; 29:231-236. [PMID: 30615013 DOI: 10.1097/cmr.0000000000000573] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Until now, malignancy has been considered a cellular problem represented by the perturbed (uncontrolled) division of the cells associated with invasion and metastasis. Contrary to this classical approach, a new perspective suggests that cancerous disease is, in fact, a supracellular problem represented by inadequate evolution of complex supracellular processes (embryogenesis, development, regeneration, etc.). Such complex processes would be disconnected from the real needs of the body, inducing unnecessary or even dangerous events such as an exacerbated rate of the cell division, angiogenesis, immunosuppression (specific to embryogenesis and melanoma), invasion (mediated by trophoblastic/placental factors in melanoma), and migration (specific to neural crest cells, which generate melanocytes - the most common origin for melanoma). As a result, a correct and comprehensive interpretation of cancer (causes, evolution, therapy, and prevention) should be conducted from a supracellular perspective. After presenting the supracellular perspective, this article further investigates the favorable evolution of malignant melanoma in two distinct situations: in patients receiving no therapy and in patients treated with immune-checkpoint inhibitors. In patients receiving no therapy, spontaneous regressions of melanoma could be the result of several autoimmune reactions (inducing not only melanoma regression but also vitiligo, an autoimmune event frequently associated with melanoma). Patients treated with immune-checkpoint inhibitors develop similar autoimmune reactions, which are clearly correlated with better therapeutic results. The best example is vitiligo, which is considered a positive prognostic factor for patients receiving immune-checkpoint inhibitors. This finding indicates that immune-checkpoint inhibitors induce distinct types of autoimmune events, some corresponding to specific favorable autoimmune mechanisms (favoring tumor regression) and others to common unfavorable adverse reactions (which should be avoided or minimized). In conclusion, the spectrum of autoimmune reactions induced by immune-checkpoint inhibitors should be restricted in the near future to only these specific favorable autoimmune mechanisms. In this way, the unnecessary autoimmune reactions/autoaggressions could be avoided (a better quality of life), and treatment specificity and efficiency should increase (a higher response rate for melanoma therapy).
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94
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Hughes MS, Zheng H, Zubiri L, Molina GE, Chen ST, Mooradian MJ, Allen IM, Reynolds KL, Dougan M. Colitis after checkpoint blockade: A retrospective cohort study of melanoma patients requiring admission for symptom control. Cancer Med 2019; 8:4986-4999. [PMID: 31286682 PMCID: PMC6718531 DOI: 10.1002/cam4.2397] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/28/2019] [Accepted: 06/14/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (CPIs) have revolutionized oncologic therapy but can lead to immune-related adverse events (irAEs). Corticosteroids are first-line treatment with escalation to biologic immunosuppression in refractory cases. CPI-related gastroenterocolitis (GEC) affects 20%-50% of patients receiving CPIs and can carry significant morbidity and mortality. Severe CPI-related GEC is not well-described. We present the clinical characterization of all CPI-related GEC requiring admission at a single institution. METHODS Clinical, laboratory, radiographic, and endoscopic data were extracted from charts of all melanoma patients ≥18 years of age admitted to one institution for CPI-related GEC, from February 5, 2011 to December 13, 2016. Patients were followed until December 31, 2017 for further admissions. Survival, outcomes, and pharmaceutical-use analyses were performed. RESULTS Median time-to-admission from initial CPI exposure was 73.5 days. Median length of stay was 4.5 days. About 50.0% required second-line immunosuppression. Readmission for recrudescence occurred in 33.3%. Common Terminology Criteria for Adverse Events (CTCAE) grade was not significantly associated with outcomes. Hypoalbuminemia (P = 0.005), relative lymphopenia (P = 0.027), and decreased lactate dehydrogenase (P = 0.026) were associated with second-line immunosuppression. There was no difference in progression-free survival (PFS) or OS (P = 0.367, 0.400) for second-line immunosuppression. Subgroup analysis showed that early corticosteroid administration (P = 0.045) was associated with decreased PFS. CONCLUSIONS Severe CPI-related GEC typically manifests within 3 months of immunotherapy exposure. Rates of second-line immunosuppression and readmission for recrudescence were high. CTCAE grade did not capture the degree of severity in our cohort. Second-line immunosuppression was not associated with poorer oncologic outcomes; however, early corticosteroid exposure was associated with decreased PFS. Further investigation is warranted.
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Affiliation(s)
- Michael S. Hughes
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Hui Zheng
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Leyre Zubiri
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Gabriel E. Molina
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Steven T. Chen
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
- Department of DermatologyMassachusetts General HospitalBostonMassachusetts
| | - Meghan J. Mooradian
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
- Massachusetts General Hospital Cancer CenterBostonMassachusetts
| | - Ian M. Allen
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Kerry L. Reynolds
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
- Massachusetts General Hospital Cancer CenterBostonMassachusetts
| | - Michael Dougan
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
- Division of GastroenterologyMassachusetts General HospitalBostonMassachusetts
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95
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Badran YR, Cohen JV, Brastianos PK, Parikh AR, Hong TS, Dougan M. Concurrent therapy with immune checkpoint inhibitors and TNFα blockade in patients with gastrointestinal immune-related adverse events. J Immunother Cancer 2019; 7:226. [PMID: 31439050 PMCID: PMC6704680 DOI: 10.1186/s40425-019-0711-0] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/14/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) have demonstrated remarkable efficacy as cancer therapeutics, however, their use remains limited due to the development of immune related adverse events (irAEs). Immune related enterocolitis (irEC) is among the most common severe irAEs leading to the discontinuation of ICIs. Inhibitors of tumor necrosis factor alpha (anti-TNFα) have been used to treat irEC. Recent animal studies have shown that concurrent treatment with anti-TNFα and ICIs improves tumor responses and decreases colitis severity. This approach has not yet been studied in prospective trials in humans. Here we describe, for the first time, the outcomes of patients who were treated concurrently with anti-TNFα and one or two ICIs. CASE PRESENTATIONS Five patients with different primary malignancies were treated with ipilimumab/nivolumab (2 patients), pembrolizumab (1 patient), ipilimumab (1 patient), or cemiplimab (1 patient). All patients developed irEC within 40 days of their first ICI dose. The patients presented with a combination of upper and lower gastrointestinal symptoms and subsequently underwent upper endoscopy and/or lower endoscopy. Endoscopy results demonstrated a spectrum of acute inflammatory changes across the gastrointestinal tract. Steroid therapy was used as first line treatment. To prevent prolonged steroid use and recurrence of gastrointestinal inflammation after resumption of cancer therapy, patients were treated concurrently with infliximab and ICI. Patients tolerated further ICI therapy with no recurrence of symptoms. Repeat endoscopies showed resolution of acute inflammation and restaging imaging showed no cancer progression. CONCLUSIONS Concurrent treatment with anti-TNFα and ICI appears to be safe, facilitates steroid tapering, and prevents irEC. Prospective clinical trials are needed to assess the outcomes of this treatment modality.
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Affiliation(s)
- Yousef R Badran
- Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Justine V Cohen
- Harvard Medical School, Boston, MA, 02115, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Priscilla K Brastianos
- Harvard Medical School, Boston, MA, 02115, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Aparna R Parikh
- Harvard Medical School, Boston, MA, 02115, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Theodore S Hong
- Harvard Medical School, Boston, MA, 02115, USA
- Department of Radiation Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Michael Dougan
- Harvard Medical School, Boston, MA, 02115, USA.
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA.
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96
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Hashemi M, Karami S, Sarabandi S, Moazeni-Roodi A, Małecki A, Ghavami S, Wiechec E. Association between PD-1 and PD-L1 Polymorphisms and the Risk of Cancer: A Meta-Analysis of Case-Control Studies. Cancers (Basel) 2019; 11:cancers11081150. [PMID: 31405171 PMCID: PMC6721817 DOI: 10.3390/cancers11081150] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 02/07/2023] Open
Abstract
A number of case-control studies regarding the association of the polymorphisms in the programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) genes with the risk of cancer have yielded inconsistent findings. Therefore, we have conducted a comprehensive, updated meta-analysis study to identify the impact of PD-1 and PD-L1 polymorphisms on overall cancer susceptibility. The findings revealed that PD-1 rs2227981 and rs11568821 polymorphisms significantly decreased the overall cancer risk (Odds Ratio (OR) = 0.82, 95% CI = 0.68–0.99, p = 0.04, TT vs. CT+CC; OR = 0.79, 95% CI = 0.67–0.94, p = 0.006, AG vs. GG, and OR = 0.82, 95% CI = 0.70–0.96, p = 0.020, AG+AA vs. GG, respectively), while PD-1 rs7421861 polymorphism significantly increased the risk of developing cancer (OR = 1.16, 95% CI = 1.02–1.33, p = 0.03, CT vs. TT). The PD-L1 rs4143815 variant significantly decreased the risk of cancer in homozygous (OR = 0.62, 95% CI = 0.41–0.94, p = 0.02), dominant (OR = 0.70, 95% CI = 0.50–0.97, p = 0.03), recessive (OR = 0.76, 95% CI = 0.60–0.96, p = 0.02), and allele (OR = 0.78, 95% CI = 0.63–0.96, p = 0.02) genetic models. No significant association between rs2227982, rs36084323, rs10204525, and rs2890658 polymorphisms and overall cancer risk has been found. In conclusions, the results of this meta-analysis have revealed an association between PD-1 rs2227981, rs11568821, rs7421861, as well as PD-L1 rs4143815 polymorphisms and overall cancer susceptibility.
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Affiliation(s)
- Mohammad Hashemi
- Genetics of Non-communicable Disease Research Center, Zahedan University of Medical Sciences, Zahedan 9816743463, Iran.
- Department of Clinical Biochemistry, School of Medicine, Zahedan University of Medical Sciences, Zahedan 9816743175, Iran.
| | - Shima Karami
- Department of Clinical Biochemistry, School of Medicine, Zahedan University of Medical Sciences, Zahedan 9816743175, Iran
| | - Sahel Sarabandi
- Department of Clinical Biochemistry, School of Medicine, Zahedan University of Medical Sciences, Zahedan 9816743175, Iran
| | - Abdolkarim Moazeni-Roodi
- Department of Clinical Biochemistry, Iranshahr University of Medical Sciences, Iranshahr 9916643535, Iran
| | - Andrzej Małecki
- Instititute of Physiotherapy and Health Sciences, The Jerzy Kukuczka Academy of Physical Education in Katowice, 40-065 Katowice, Poland
| | - Saeid Ghavami
- Department of Human Anatomy and Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0J9, Canada.
- Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba, Winnipeg, MB R3E 3P5, Canada.
| | - Emilia Wiechec
- Department of Clinical and Experimental Medicine, Linköping University, 58183 Linköping, Sweden.
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97
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Evens A, Cyriac G, Jeong D, Araujo C, Gage K, Rose T. A Pictorial Essay of Immunotherapy: Complications that Internists Will See, Whether They Like it or Not. Am J Med 2019; 132:808-815. [PMID: 30849381 DOI: 10.1016/j.amjmed.2019.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/01/2019] [Accepted: 02/15/2019] [Indexed: 12/13/2022]
Abstract
Immunotherapy agents for treatment of cancer have been investigated for decades, but effective agents have only recently been identified and are increasingly being used in multiple cancer types. There is growing recognition of adverse side effects in multiple organ systems mediated by dysregulation of the immune system, which can be exacerbated by comorbidities often found in cancer patients such as chronic lung disease, diabetes, and hypertension. As a result, internists and other nononcology clinicians are routinely encountering immunotherapy patients who present with a remarkably wide range of symptoms. Here, we present the radiographic manifestations of common side effects from immunotherapy agents. An accurate diagnosis is critical in these often-complex clinical settings in which the consequences of the underlying cancer and other comorbidities must be distinguished from the variable manifestations of treatment toxicity.
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Affiliation(s)
| | | | - Daniel Jeong
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla
| | - Cyrillo Araujo
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla
| | - Kenneth Gage
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla
| | - Trevor Rose
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla
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98
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Jafarnejad M, Gong C, Gabrielson E, Bartelink IH, Vicini P, Wang B, Narwal R, Roskos L, Popel AS. A Computational Model of Neoadjuvant PD-1 Inhibition in Non-Small Cell Lung Cancer. AAPS JOURNAL 2019; 21:79. [PMID: 31236847 PMCID: PMC6591205 DOI: 10.1208/s12248-019-0350-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/07/2019] [Indexed: 12/16/2022]
Abstract
Immunotherapy and immune checkpoint blocking antibodies such as anti-PD-1 are approved and significantly improve the survival of advanced non-small cell lung cancer (NSCLC) patients, but there has been little success in identifying biomarkers capable of separating the responders from non-responders before the onset of the therapy. In this study, we developed a quantitative system pharmacology (QSP) model to represent the anti-tumor immune response in human NSCLC that integrated our knowledge of tumor growth, antigen processing and presentation, T cell activation and distribution, antibody pharmacokinetics, and immune checkpoint dynamics. The model was calibrated with the available data and was used to identify potential biomarkers as well as patient-specific response based on the patient parameters. The model predicted that in addition to tumor mutational burden (TMB), a known biomarker for anti-PD-1 therapy in NSCLC, the number of effector T cells and regulatory T cells in the tumor and blood is a predictor of the responders. Furthermore, the model simulated a set of 12 patients with known TMB and MHC/antigen-binding affinity from a recent clinical trial (ClinicalTrials.gov number, NCT02259621) on neoadjuvant nivolumab therapy in resectable lung cancer and predicted an augmented durable response in patients with adjuvant nivolumab treatment in addition to the clinical trial protocol of neoadjuvant nivolumab treatment followed by resection. Overall, the model provides a valuable framework to model tumor immunity and response to immune checkpoint blockers to enhance biomarker discovery and performing virtual clinical trials to aid in design and interpretation of the current trials with fewer patients.
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Affiliation(s)
- Mohammad Jafarnejad
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Chang Gong
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward Gabrielson
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Imke H Bartelink
- Clinical Pharmacology, Pharmacometrics and DMPK (CPD), MedImmune, South San Francisco, CA, USA.,Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paolo Vicini
- Clinical Pharmacology, Pharmacometrics and DMPK, MedImmune, Cambridge, UK
| | - Bing Wang
- Clinical Pharmacology, Pharmacometrics and DMPK (CPD), MedImmune, South San Francisco, CA, USA.,Amador Bioscience Inc., Pleasanton, CA, USA
| | | | | | - Aleksander S Popel
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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99
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Tang T, Abu-Sbeih H, Luo W, Lum P, Qiao W, Bresalier RS, Richards DM, Wang Y. Upper gastrointestinal symptoms and associated endoscopic and histological features in patients receiving immune checkpoint inhibitors. Scand J Gastroenterol 2019; 54:538-545. [PMID: 31079556 DOI: 10.1080/00365521.2019.1594356] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Immune checkpoint inhibitors (ICIs) have demonstrated effectiveness in treating many malignancies. Gastrointestinal (GI) adverse events are commonly reported; however, few reports describe upper GI tract toxic effects. We aimed to describe clinical features of upper GI injury related to ICI. Methods: We studied consecutive patients who received ICIs between April 2011 and March 2018 and developed upper GI symptoms requiring esophagogastroduodenoscopy (EGD). Results: Sixty patients developed upper GI symptoms between ICI initiation and 6 months after the last infusion. Among patients who had both EGD and colonoscopy (n = 38), 21 had endoscopic evidence of inflammation involving both the upper and lower GI tract. Overall, histological signs of inflammation of the stomach were evident in 83% of patients, but inflammation of the duodenum in 38%. Total of 42 patients had other risk factors of gastritis, i.e., chemotherapy, radiotherapy, and non-steroidal anti-inflammatory drugs. Only isolated gastric inflammation was seen on endoscopy in patients without these risk factors. The rates of ulceration were similar in the cohorts with and without other risk factors for gastritis. Isolated upper GI inflammation was related to anti-PD-1/L1 in 47% of patients. Immunosuppressive therapy in our cohort with upper GI toxicity consisted of steroids (42%) and infliximab or vedolizumab (23%). Most isolated upper GI symptoms were treated with proton pump inhibitors (65%) or H2 blockers (35%). Conclusion: We observed a correlation between ICI use and onset of upper GI inflammation even when other risk factors were excluded. Gastric involvement was evident more often than duodenal involvement on endoscopic and histological level.
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Affiliation(s)
- Tenglong Tang
- a Department of Gastroenterology, Hepatology, and Nutrition , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA.,b Department of Minimally Invasive Surgery , The Second Xiangya Hospital of Central South University , Changsha , China
| | - Hamzah Abu-Sbeih
- a Department of Gastroenterology, Hepatology, and Nutrition , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| | - Wenyi Luo
- c Division of Pathology and Laboratory Medicine , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| | - Phillip Lum
- a Department of Gastroenterology, Hepatology, and Nutrition , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| | - Wei Qiao
- d Department of Biostatistics , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| | - Robert S Bresalier
- a Department of Gastroenterology, Hepatology, and Nutrition , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| | - David M Richards
- a Department of Gastroenterology, Hepatology, and Nutrition , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| | - Yinghong Wang
- a Department of Gastroenterology, Hepatology, and Nutrition , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
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100
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Alessandrino F, Sahu S, Nishino M, Adeni AE, Tirumani SH, Shinagare AB, Awad MM. Frequency and imaging features of abdominal immune-related adverse events in metastatic lung cancer patients treated with PD-1 inhibitor. Abdom Radiol (NY) 2019; 44:1917-1927. [PMID: 30790009 DOI: 10.1007/s00261-019-01935-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate the frequency and imaging features of radiographically evident abdominal immune-related adverse events (irAEs) in patients with metastatic non-small-cell lung cancer (NSCLC) treated with PD-1 inhibitors. METHODS This retrospective study included 137 patients with metastatic NSCLC treated with PD-1 inhibitor nivolumab monotherapy (75 women; median age: 65 years), who had a baseline CT and at least one follow-up abdomen CT during therapy. Baseline and all follow-up abdominal CTs performed for monitoring of nivolumab therapy were reviewed to identify the organ-specific abdominal irAEs including colitis/enteritis, hepatitis, biliary toxicity, pancreatitis, nephritis, sarcoid-like reaction, and pancreatic and adrenal atrophy. Their frequency and imaging features were described. RESULTS Eighteen (13%) patients had radiologically identified abdominal irAEs (median 2.1 months after starting nivolumab; interquartile range 1.17-5.83 months); 16 patients developed enteritis/colitis (12 pancolitis, two segmental colitis, one enterocolitis, one enteritis), two hepatitis, one adrenalitis. One patient with hepatitis also developed colitis/enteritis. Radiographic abdominal irAE occurred after nivolumab therapy was discontinued in six patients before any subsequent therapy was started. IrAEs prompted nivolumab interruption and treatment with steroids in four patients (three colitis/enteritis, one hepatitis). Most common CT features of colitis/enteritis included mesenteric hyperemia (n = 15), bowel wall thickening (n = 13), mucosal hyperenhancement (n = 10), and fluid-filled colon (n = 9). CONCLUSION Abdominal irAEs were detected on CT in 13% of NSCLC patients treated with nivolumab, and colitis, in the pancolitis form, was the most common irAE. Given the expanding role of immunotherapy, radiologists should be aware of the frequency and imaging manifestations of abdominal irAEs and the impact on patient management.
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