101
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Reid P, Liew DF, Akruwala R, Bass AR, Chan KK. Activated osteoarthritis following immune checkpoint inhibitor treatment: an observational study. J Immunother Cancer 2021; 9:jitc-2021-003260. [PMID: 34526389 PMCID: PMC8444247 DOI: 10.1136/jitc-2021-003260] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 02/04/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but can result in toxicities, known as immune-related adverse events (irAEs), due to a hyperactivated immune system. ICI-related inflammatory arthritis has been described in literature, but herewith we introduce and characterize post-ICI-activated osteoarthritis (ICI-aOA). We conducted a multicenter, retrospective, observational study of patients with cancer treated with ICIs and diagnosed with ICI-aOA by a rheumatologist. ICI-aOA was defined by (1) an increase in non-inflammatory joint pain after ICI initiation, (2) in joints characteristically affected by osteoarthritis, and (3) lack of inflammation on exam. Cases were graded using the Common Terminology Criteria for Adverse Events (CTCAE) V.6.0 rubric for arthralgia. Response Evaluation Criteria in Solid Tumors V.1.1 (v.4.03) guidelines determined tumor response. Results were analyzed using χ2 tests of association and multivariate logistic regression. Thirty-six patients had ICI-aOA with a mean age at time of rheumatology presentation of 66 years (51–81 years). Most patients had metastatic melanoma (10/36, 28%) and had received a PD-1/PD-L1 inhibitor monotherapy (31/36, 86%) with 5/36 (14%) combination therapy. Large joint involvement (hip/knee) was noted in 53% (19/36), small joints of hand 25% (9/36), and spine 14% (5/36). Two-thirds (24/36) suffered multiple joint involvement. Three of 36 (8%) had CTCAE grade 3, 14 (39%) grade 2 and 19 (53%) grade 1 manifestations. Symptom onset ranged from 6 days to 33.8 months with a median of 5.2 months after ICI initiation; five patients suffered from ICI-aOA after ICI cessation (0.6, 3.5, 4.4, 7.3, and 15.4 months after ICI cessation). The most common form of therapy was intra-articular corticosteroid injections only (15/36, 42%) followed by non-steroidal anti-inflammatory drugs only (7/36, 20%). Twenty patients (56%) experienced other irAEs, with rheumatic and dermatological being the most common. All three patients with high-grade ICI-aOA also had another irAE diagnosis at some point after ICI initiation. ICI-aOA should be recognized as an adverse event of ICI immunotherapy. Early referral to a rheumatologist can facilitate the distinction between ICI induced inflammatory arthritis from post-ICI mechanical arthropathy, the latter of which can be managed with local therapy that will not compromise ICI efficacy.
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Affiliation(s)
- Pankti Reid
- Medicine, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - David Fl Liew
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Division of Rheumatology and Department of Clinical Pharmacology and Therapeutics, Austin Health, Heidelberg, Victoria, Australia
| | - Rajshi Akruwala
- Department of Medicine, SUNY Downstate Medical Center, New York City, New York, USA
| | - Anne R Bass
- Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Karmela K Chan
- Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
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102
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Anjohrin S, Sheahan A, Suruki R, Stark JL, Sloan VS. Occurrence of Possible Rheumatologic Immune-Related Adverse Events (rh-irAEs) Associated with Immune Checkpoint Inhibitor (ICI) Therapy. Rheumatol Ther 2021; 8:1651-1659. [PMID: 34491550 PMCID: PMC8572292 DOI: 10.1007/s40744-021-00359-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/12/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Current epidemiologic literature of rheumatologic immune-related adverse events (rh-irAEs) consists of clinical trials, case reports, or smaller, single-center series. We evaluate the occurrence of rh-irAEs during immune checkpoint inhibitor (ICI) therapy from US commercial claims data. Methods Patients newly initiating ICI therapy in commercial claims data were eligible for inclusion. Rh-irAEs were defined using ≥ 1 International Classification of Diseases (ICD)-9 or ICD-10-Clinical Modification (CM) claims for selected events, ranging from joint pain and myalgia to ankylosing spondylitis and psoriasis. The percentage of patients experiencing rh-irAEs after ICI initiation was determined. Results A total of 5722 patients initiating an ICI between January 1, 2012, and June 30, 2018, were included; 201 patients (3.5%) had a history of rheumatic disease. Among the 5521 patients without a history of rheumatic disease, 29.6% experienced ≥ 1 rh-irAE in follow-up, decreasing to 22.6% when assessing events for which there was no diagnostic history. Limiting to claims for rh-irAE with a rheumatologist provider, the proportion of patients experiencing an event decreased to 0.9%. Among patients with a history of rheumatic disease, 71.6% experienced ≥ 1 rh-irAE. Limiting to events for which the patient did not have a history during baseline, 35.3% experienced an event. Conclusions Occurrence of rh-irAEs during ICI use is higher in patients with pre-existing rheumatic disease compared to those with no pre-existing rheumatic disease. However, the most common events were not definitive rheumatic diseases but rather symptoms, such as pain in joints. Occurrence of events associated with a rheumatologist provider was substantially lower, suggesting that either patients are not referred to a rheumatologist or referral does not result in confirmation of the diagnosis by the rheumatologist. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00359-z.
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Affiliation(s)
| | - Anna Sheahan
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA, 30080, USA
| | - Robert Suruki
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA, 30080, USA
| | | | - Victor S Sloan
- The Peace Corps, Washington, DC, USA.,Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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103
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Boppana SH, Dulla NR, Beutler BD, Gullapalli N, Kaur R. Drug-Associated Eosinophilic Fasciitis: A Case of Eosinophilic Fasciitis Secondary to Cemiplimab Therapy. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932888. [PMID: 34403405 PMCID: PMC8380854 DOI: 10.12659/ajcr.932888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/07/2021] [Accepted: 07/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Eosinophilic fasciitis, also known as Shulman syndrome, is a rare inflammatory condition characterized by diffuse erythema and progressive collagenous thickening of the subcutaneous fascia. The underlying cause remains to be definitively established; however, several drugs have been linked to this uncommon clinical entity. We present a rare case of eosinophilic fasciitis secondary to immune checkpoint inhibitor therapy. CASE REPORT A 72-year-old woman with metastatic cutaneous squamous cell carcinoma presented to the rheumatology clinic for evaluation of joint pain that developed 3 weeks after beginning treatment with cemiplimab. The correlation of clinical history and physical examination was most consistent with osteoarthritis. Symptoms improved after a short course of low-dose prednisone. The patient continued cemiplimab therapy for approximately 1 year and was subsequently transitioned to carboplatin and radiation therapy. However, relapse occurred shortly thereafter, and cemiplimab was restarted. Two weeks later, the patient developed severe joint pain, morning stiffness, and extensive cutaneous discoloration and induration. A skin biopsy was performed. Microscopic examination of a tissue sample showed a mononuclear infiltrate with plasma cells and eosinophils. A diagnosis of eosinophilic fasciitis was established. Cemiplimab was held and the patient was treated with hydroxychloroquine, prednisone, and sulfasalazine. Symptoms improved within 1 week. CONCLUSIONS Eosinophilic fasciitis is a rare but important adverse effect of immune checkpoint inhibitors. Individuals receiving immunotherapy should be monitored closely for symptoms of eosinophilic fasciitis, as prompt treatment is essential to prevent long-term complications.
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Affiliation(s)
- Sri Harsha Boppana
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Nageswara Rao Dulla
- Department of Internal Medicine, Mythri Multispecialty Hospital, Guntur, India
| | - Bryce D. Beutler
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Nageshwara Gullapalli
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Ratinder Kaur
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
- Department of Rheumatology, Arthritis Consultants, Reno, NV, USA
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104
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Harris JA, Huang K, Miloslavsky E, Hanna GJ. Sicca syndrome associated with immune checkpoint inhibitor therapy. Oral Dis 2021; 28:2083-2092. [PMID: 34379884 DOI: 10.1111/odi.14000] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/07/2021] [Accepted: 08/03/2021] [Indexed: 12/17/2022]
Abstract
Cancer immunotherapy, which seeks to stimulate a patient's own immune system to combat cancer, is quickly becoming a central pillar of cancer therapeutics and has resulted in the development of many novel anticancer therapies. One subtype of cancer immunotherapy, immune checkpoint inhibitors (ICIs), has revolutionized cancer treatment and changed the standard of care for multiple indications. However, the advent of ICIs has produced a wide variety of inflammatory side effects termed immune-related adverse events (IRAEs), including ICI-induced Sicca syndrome. This article outlines the clinical features of ICI-induced Sicca syndrome and assesses its reported incidence in clinical trials, case series, and case reports across numerous cancers and treatment modalities. Presentations of ICI-induced Sicca syndrome in patients with pre-existing Sjӧgren's disease and with extra-glandular manifestations will also be explored. The pathophysiological mechanisms underlying IRAEs, including ICI-induced Sicca syndrome, will be evaluated through an examination of existing literature. Finally, the various treatment and management strategies as well as aims for future work will be discussed and reviewed.
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Affiliation(s)
- Jack A Harris
- Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Kevin Huang
- Harvard Medical School, Boston, Massachusetts, USA
| | - Eli Miloslavsky
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Glenn J Hanna
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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105
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Wojtukiewicz MZ, Rek MM, Karpowicz K, Górska M, Polityńska B, Wojtukiewicz AM, Moniuszko M, Radziwon P, Tucker SC, Honn KV. Inhibitors of immune checkpoints-PD-1, PD-L1, CTLA-4-new opportunities for cancer patients and a new challenge for internists and general practitioners. Cancer Metastasis Rev 2021; 40:949-982. [PMID: 34236546 PMCID: PMC8556173 DOI: 10.1007/s10555-021-09976-0] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/07/2021] [Indexed: 12/11/2022]
Abstract
The treatment of cancer patients with immune checkpoint inhibitors (ICI) (anti-CTLA-4, anti-PD-1, anti-PD-L1, combined therapy anti-PD-1/PD-L1 with anti-CTLA-4) has without doubt been a significant breakthrough in the field of oncology in recent years and constitutes a major step forward as a novel type of immunotherapy in the treatment of cancer. ICIs have contributed to a significant improvement in the outcome of treatment and prognosis of patients with different types of malignancy. With the expansion of the use of ICIs, it is expected that caregivers will face new challenges, namely, they will have to manage the adverse side effects associated with the use of these drugs. New treatment options pose new challenges not only for oncologists but also for specialists in other clinical fields, including general practitioners (GPs). They also endorse the need for taking a holistic approach to the patient, which is a principle widely recognized in oncology and especially relevant in the case of the expanding use of ICIs, which may give rise to a wide variety of organ complications resulting from treatment. Knowledge and awareness of the spectrum of immune-related adverse events (irAEs) will allow doctors to qualify patients for treatment more appropriately, prevent complications, correctly recognize, and ultimately treat them. Additionally, patients with more non-specific symptoms would be expected, in the first instance, to consult their general practitioners, as complications may appear even after the termination of treatment and do not always proceed in line with disease progression. Dealing with any iatrogenic complications, will not only be the remit of oncologists but because of the likelihood that specific organs may be affected, is likely to extend also to specialists in various fields of internal medicine. These specialists, e.g., endocrinologists, dermatologists, pulmonologists, and gastroenterologists, are likely to receive referrals for patients suffering from specific types of adverse events or will be asked to provide care in cases requiring hospitalization of patients with complications in their field of expertise. In view of these considerations, we believe that there is an urgent need for multidisciplinary teamwork in the treatment of cancer patients undergoing immunotherapy and suffering the consequent adverse reactions to treatment.
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Affiliation(s)
- Marek Z Wojtukiewicz
- Department of Oncology, Medical University of Bialystok, Bialystok, Poland. .,Department of Clinical Oncology, Comprehensive Cancer Center, Białystok, Poland.
| | - Magdalena M Rek
- Department of Oncology, Medical University of Bialystok, Bialystok, Poland.,Department of Clinical Oncology, Comprehensive Cancer Center, Białystok, Poland
| | - Kamil Karpowicz
- Department of Clinical Oncology, Comprehensive Cancer Center, Białystok, Poland
| | - Maria Górska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Barbara Polityńska
- Department of Philosophy and Human Psychology, Medical University of Białystok, Białystok, Poland.,Robinson College, Cambridge University, Cambridge, UK
| | - Anna M Wojtukiewicz
- Department of Philosophy and Human Psychology, Medical University of Białystok, Białystok, Poland
| | - Marcin Moniuszko
- Department of Allergology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland.,Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Radziwon
- Regional Centre for Transfusion Medicine, Bialystok, Poland.,Department of Hematology, Medical University of Bialystok, Bialystok, Poland
| | - Stephanie C Tucker
- Bioactive Lipids Research Program, Department of Pathology-School of Medicine, Detroit, MI, USA.,Department of Oncology, Karmanos Cancer Institute, Detroit, MI, USA
| | - Kenneth V Honn
- Bioactive Lipids Research Program, Department of Pathology-School of Medicine, Detroit, MI, USA.,Department of Chemistry, Wayne State University, Detroit, MI, USA.,Department of Oncology, Wayne State University, Detroit, MI, USA
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106
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Ramahi A, Chan KH, Lim SL, Shaaban HS. Cryoglobulinemia unmasked by nivolumab in a patient with hepatitis C-induced hepatocellular carcinoma: A case report and literature review. Int J Crit Illn Inj Sci 2021; 11:95-97. [PMID: 34395211 PMCID: PMC8318163 DOI: 10.4103/ijciis.ijciis_11_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/17/2020] [Accepted: 05/15/2020] [Indexed: 01/23/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is ranked the fifth-most common cancer in men and ninth most common cancer in women. Immunotherapy has been shown effective in malignancies refractory to chemotherapy and has been used as a second-line therapies in many advanced cancers, including HCC. The advent of immunotherapy has resulted in a brand-new set of side effects, and it has been proposed that it was related to over activated immune system. Herein, we presented the case of 59-year-old African American gentlemen who was diagnosed with HCC caused by Hepatitis C virus, for which he was started on chemotherapy and immunotherapy. However, the patient developed cryoglobulinemia that prompted stopping both therapies and giving rituximab and steroids. We believe that the mixed cryoglobulinemia was unmasked by immunotherapy in our patient. To our knowledge, this is one of the few first cases to describe such adverse effect from immune checkpoint inhibitors.
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Affiliation(s)
- Amr Ramahi
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Kok Hoe Chan
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Su Lin Lim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Hamid S Shaaban
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA.,Department of Internal Medicine, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA.,Department of Hematology/Oncology, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
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107
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Wesley SF, Haggiagi A, Thakur KT, De Jager PL. Neurological Immunotoxicity from Cancer Treatment. Int J Mol Sci 2021; 22:6716. [PMID: 34201529 PMCID: PMC8268562 DOI: 10.3390/ijms22136716] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 12/24/2022] Open
Abstract
The emergence of immune-based treatments for cancer has led to a growing field dedicated to understanding and managing iatrogenic immunotoxicities that arise from these agents. Immune-related adverse events (irAEs) can develop as isolated events or as toxicities affecting multiple body systems. In particular, this review details the neurological irAEs from immune checkpoint inhibitors (ICI) and chimeric antigen receptor (CAR) T cell immunotherapies. The recognition and treatment of neurological irAEs has variable success, depending on the severity and nature of the neurological involvement. Understanding the involved mechanisms, predicting those at higher risk for irAEs, and establishing safety parameters for resuming cancer immunotherapies after irAEs are all important fields of ongoing research.
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Affiliation(s)
- Sarah F. Wesley
- Multiple Sclerosis Center, Department of Neurology, Division of Neuroimmunology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center-New York Presbyterian Hospital, 710 W 168th Street, Neurological Institute, New York, NY 10032, USA;
| | - Aya Haggiagi
- Department of Neurology, Division of Neuro-Oncology, Columbia University Vagelos College of Physicians and Surgeons, Herbert Irving Comprehensive Cancer Center, New York-Presbyterian Hospital, New York, NY 10032, USA;
| | - Kiran T. Thakur
- Program in Neuroinfectious Diseases and Related Disorders, Division of Critical Care and Hospitalist Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY 10032, USA;
| | - Philip L. De Jager
- Multiple Sclerosis Center, Department of Neurology, Division of Neuroimmunology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center-New York Presbyterian Hospital, 710 W 168th Street, Neurological Institute, New York, NY 10032, USA;
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108
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Rheumatic Immune-Related Adverse Events-A Consequence of Immune Checkpoint Inhibitor Therapy. BIOLOGY 2021; 10:biology10060561. [PMID: 34203101 PMCID: PMC8235766 DOI: 10.3390/biology10060561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 12/04/2022]
Abstract
Simple Summary Cancer therapy has evolved over the years, immunotherapy being the most used for untreatable malignant tumors. Immune checkpoint inhibitors decrease the ability of tumor cells to escape the immune system. Although immune checkpoint inhibitors have a significant impact in the treatment of cancer, they are associated with various adverse effects, mostly inflammation. The adverse events related to the immune system may affect basically every tissue in the human body, including the digestive tract, endocrine glands, liver, skin, cardiovascular, pulmonary and, also, rheumatic systems. In this review, we address the rheumatic immune-related adverse events related to immunotherapy by depicting the characteristics, diagnostic approach and treatment options. Abstract The advent of immunotherapy has changed the management and therapeutic methods for a variety of malignant tumors in the last decade. Unlike traditional cytotoxic chemotherapy, which works by interfering with cancer cell growth via various pathways and stages of the cell cycle, cancer immunotherapy uses the immune system to reduce malignant cells’ ability to escape the immune system and combat cell proliferation. The widespread use of immune checkpoint inhibitors (ICIs) over the past 10 years has presented valuable information on the profiles of toxic adverse effects. The attenuation of T-lymphocyte inhibitory mechanisms by ICIs results in immune system hyperactivation, which, as expected, is associated with various adverse events defined by inflammation. These adverse events, known as immune-related adverse events (ir-AEs), may affect any type of tissue throughout the human body, which includes the digestive tract, endocrine glands, liver and skin, with reports of cardiovascular, pulmonary and rheumatic ir-AEs as well. The adverse events that arise from ICI therapy are both novel and unique compared to those of the conventional treatment options. Thus, they require a multidisciplinary approach and continuous updates on the diagnostic approach and management.
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109
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Botta C, Agostino RM, Dattola V, Cianci V, Calandruccio ND, Bianco G, Mafodda A, Maisano R, Iuliano E, Orizzonte G, Mazzacuva D, Falzea AC, Saladino RE, Giannicola R, Restifo G, Aguglia U, Caraglia M, Correale P. Myositis/Myasthenia after Pembrolizumab in a Bladder Cancer Patient with an Autoimmunity-Associated HLA: Immune-Biological Evaluation and Case Report. Int J Mol Sci 2021; 22:6246. [PMID: 34200673 PMCID: PMC8230397 DOI: 10.3390/ijms22126246] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 02/07/2023] Open
Abstract
Pembrolizumab (mAb to PD-1) has been recently approved for the therapy of pretreated urothelial cancer. Despite the efficacy, it is often accompanied by unpredictable and sometime severe immune-related (ir) adverse events (AEs). Here, we report the clinical and immune-biological characterization of a patient with a metastatic bladder cancer who developed myositis signs (M) and a myasthenia-like syndrome (MLS) during treatment with pembrolizumab. The patient presented an autoimmunity-associated HLA haplotype (HLA-A*02/HLA-B*08/HLA-C*07/HLA-DRB1*03) and experienced an increase in activated CD8 T-cells along the treatment. The symptomatology regressed after pembrolizumab discontinuation and a pyridostigmine and steroids-based therapy. This is the first report of concurrent M and MLS appearance in cancer patients receiving pembrolizumab. More efforts are needed to define early the risk and the clinical meaning of irAEs in this setting.
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Affiliation(s)
- Cirino Botta
- Unit of Hematology, Azienda Ospedaliera “Annunziata”, 87100 Cosenza, Italy
- Hematology Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90128 Palermo, Italy
| | - Rita Maria Agostino
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Vincenzo Dattola
- Unit of Neurology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (V.D.); (V.C.); (U.A.)
| | - Vittoria Cianci
- Unit of Neurology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (V.D.); (V.C.); (U.A.)
| | - Natale Daniele Calandruccio
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Giovanna Bianco
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Antonino Mafodda
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Roberto Maisano
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Eleonora Iuliano
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Giovanna Orizzonte
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Domenico Mazzacuva
- Laboratory of Autoimmunity, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy;
| | - Antonia Consuelo Falzea
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Rita Emilena Saladino
- HLA Tissue Typing Laboratory, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy;
| | - Rocco Giannicola
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Giorgio Restifo
- Nuclear Medicine Unit, Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy;
| | - Umberto Aguglia
- Unit of Neurology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (V.D.); (V.C.); (U.A.)
| | - Michele Caraglia
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy;
- Laboratory of Precision and Molecular Oncology, Biogem Scarl, Institute of Genetic Research, 83031 Ariano Irpino, Italy
| | - Pierpaolo Correale
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
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110
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Mamoor M, Postow MA, Lavery JA, Baxi SS, Khan N, Mao JJ, Rogak LJ, Sidlow R, Thom B, Wolchok JA, Korenstein D. Quality of life in long-term survivors of advanced melanoma treated with checkpoint inhibitors. J Immunother Cancer 2021; 8:jitc-2019-000260. [PMID: 32152222 PMCID: PMC7061889 DOI: 10.1136/jitc-2019-000260] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2020] [Indexed: 01/12/2023] Open
Abstract
Background Immune checkpoint inhibitors (CIs) have revolutionized treatment of advanced melanoma, leading to an emerging population of long-term survivors. Survivors’ quality of life (QOL) and symptom burden are poorly understood. We set out to evaluate symptom burden and QOL in patients with advanced melanoma alive more than 1 year after initiating CI therapy. Methods Cross-sectional surveys, accompanied by chart review of patients with advanced melanoma treated with CIs at Memorial Sloan Kettering Cancer Center, completed therapy, and were alive >1 year after treatment initiation. Surveys were administered between February and August 2018. Surveys included: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, EuroQOL, items from Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events and Fatigue Severity Scale. Results We included 90 patients. The most common CI regimens were ipilimumab plus nivolumab (53%) and pembrolizumab (41%); most patients (71%) were not treated in clinical trials. Median time from CI therapy initiation was 40 months and from last dose was 28 months. Fatigue was reported by 28%, with higher fatigue scores in women than men; 12% reported difficulty sleeping. Aching joints (17%) and muscles (12%) were fairly common. Level of functioning was generally high. Overall QOL was excellent though 40% reported ‘some or moderate’ problems with anxiety/depression and 31% with pain/discomfort. Conclusions After CI therapy, long-surviving advanced melanoma patients commonly report fatigue but otherwise have moderate symptom burden and good QOL. Ensuring appropriate symptom management will optimize clinical outcomes for these patients.
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Affiliation(s)
- Maha Mamoor
- Health Outcomes Group, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael A Postow
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jessica A Lavery
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Niloufer Khan
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jun J Mao
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lauren J Rogak
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Robert Sidlow
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Bridgette Thom
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jedd A Wolchok
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Deborah Korenstein
- Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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111
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Brahmer JR, Abu-Sbeih H, Ascierto PA, Brufsky J, Cappelli LC, Cortazar FB, Gerber DE, Hamad L, Hansen E, Johnson DB, Lacouture ME, Masters GA, Naidoo J, Nanni M, Perales MA, Puzanov I, Santomasso BD, Shanbhag SP, Sharma R, Skondra D, Sosman JA, Turner M, Ernstoff MS. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse events. J Immunother Cancer 2021; 9:e002435. [PMID: 34172516 PMCID: PMC8237720 DOI: 10.1136/jitc-2021-002435] [Citation(s) in RCA: 338] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are the standard of care for the treatment of several cancers. While these immunotherapies have improved patient outcomes in many clinical settings, they bring accompanying risks of toxicity, specifically immune-related adverse events (irAEs). There is a need for clear, effective guidelines for the management of irAEs during ICI treatment, motivating the Society for Immunotherapy of Cancer (SITC) to convene an expert panel to develop a clinical practice guideline. The panel discussed the recognition and management of single and combination ICI irAEs and ultimately developed evidence- and consensus-based recommendations to assist medical professionals in clinical decision-making and to improve outcomes for patients.
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Affiliation(s)
- Julie R Brahmer
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Hamzah Abu-Sbeih
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Paolo Antonio Ascierto
- Unit of Melanoma Cancer Immunotherapy and Innovative Therapy, National Tumour Institute IRCCS Fondazione 'G. Pascale', Napoli, Italy
| | - Jill Brufsky
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura C Cappelli
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frank B Cortazar
- Massachusetts General Hospital, Boston, Massachusetts, USA
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - David E Gerber
- Department of Hematology and Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lamya Hamad
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Eric Hansen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Mario E Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory A Masters
- Department of Medicine, Helen F. Graham Cancer Center, Newark, Delaware, USA
| | - Jarushka Naidoo
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
- Department of Oncology, Beaumont Hospital Dublin, The Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Michele Nanni
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Satish P Shanbhag
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Cancer Specialist of North Florida, Fleming Island, Florida, USA
| | - Rajeev Sharma
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Dimitra Skondra
- Department of Ophthalmology and Visual Science, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jeffrey A Sosman
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Medical Center, Chicago, Illinois, USA
| | - Michelle Turner
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Marc S Ernstoff
- Division of Cancer Treatment & Diagnosis, National Cancer Institute, Rockville, Maryland, USA
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112
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Kang MJ. Management of adverse events in cancer treatment with immune checkpoint inhibitors. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.5.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The use of immune checkpoint inhibitors is associated with a spectrum of immune-related adverse events related to the mechanism of action which is quite different from that of cytotoxic chemotherapy. Adverse effects can affect multiple organs of the body and are most common in the skin, gastrointestinal tract, lungs, and endocrine tissues, including the thyroid, adrenal gland, pituitary gland, as well as musculoskeletal, renal, nervous, hematologic, cardiovascular, and ocular systems. Any changes should be considered as being related to treatment with immune checkpoint inhibitors. Adverse events are very infrequent, but may be very serious and, even lethal, such as neurological disorders and myocarditis. When compared with standard chemotherapeutic agents, programmed death 1/programmed deathligand 1inhibitors are associated with a lower incidence of bone marrow suppression, anorexia, nausea, vomiting, and diarrhea. Immune checkpoint inhibitor therapy can usually continue in the presence of mild immune-related adverse events with close monitoring. However, moderate to severe immune-related adverse events may be associated with a severe decline in organ function and quality of life, and may result in fatal outcomes. Hence, these toxicities require early detection and proper management. The management of immune-related adverse events usually involves corticosteroid therapy or the use of immunomodulators. The use of immune checkpoint inhibitors in patients with preexisting autoimmune disease or a history of prior organ transplant should include careful consideration and a robust discussion of potential risks and benefits.
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113
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Michailidou D, Khaki AR, Morelli MP, Diamantopoulos L, Singh N, Grivas P. Association of blood biomarkers and autoimmunity with immune related adverse events in patients with cancer treated with immune checkpoint inhibitors. Sci Rep 2021; 11:9029. [PMID: 33907229 PMCID: PMC8079370 DOI: 10.1038/s41598-021-88307-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/29/2021] [Indexed: 02/08/2023] Open
Abstract
Patients with cancer treated with immune checkpoint inhibitors (ICIs) develop immune related adverse events (irAEs), however biomarkers are lacking. We hypothesized that clinicopathologic and laboratory factors would be associated with irAE risk and overall survival (OS) in this population. In a retrospective study of patients treated with ICIs we collected clinicopathologic, laboratory, irAEs and outcomes data. The association between baseline blood biomarkers, clinicopathologic features and irAEs was assessed by logistic regression adjusting for age, sex, smoking, cancer type, performance status, concomitant other systemic therapy, history of autoimmune disease (AD), chronic infection and pre-existing systemic steroid use (regardless of dose). Optimal cutoff values of biomarkers were identified by recursive partitioning analysis. 470 patients were identified; 156 (33%) developed irAEs, which were associated with baseline absolute lymphocyte count > 2.6 k/ul (adjusted [a]OR: 4.30), absolute monocyte count > 0.29 k/ul (aOR: 2.34) and platelet count > 145 k/ul (aOR: 2.23), neutrophil to lymphocyte ratio (NLR) ≤ 5.3 (aOR: 2.07) and monocyte to lymphocyte ratio (MLR) ≤ 0.73 (aOR: 2.96), as well as platelet to lymphocyte ratio ≤ 534 (aOR: 5.05). Patients with pre-existing AD (aOR: 2.57), family history of AD (aOR: 5.98), and ICI combination (aOR: 2.00) had higher odds of irAEs. Baseline NLR ≤ 5.3 (aHR: 0.68), MLR ≤ 0.73 (aHR: 0.43), PLT > 145 (aHR: 0.48) and PLR ≤ 534 (aHR: 0.48) were associated with longer OS. irAEs were associated with autoimmune history, ICI combination and baseline laboratory measurements. Lower NLR, MLR and PLR may have favorable prognostic value. Our hypothesis-generating findings require validation in larger prospective studies.
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Affiliation(s)
- Despina Michailidou
- Division of Rheumatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ali Raza Khaki
- Division of Medical Oncology, Department of Medicine, University of Washington, 1144 Eastlake Ave E, LG-465, Seattle, WA, 98109, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle, WA, 98109, USA.,Seattle Cancer Care Alliance, 1144 Eastlake Ave E, LG-465, Seattle, WA, 98109, USA.,Division of Oncology, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Maria Pia Morelli
- Gastrointestinal Medical Oncology, The University of Texas, MD Anderson Comprehensive Cancer Center, Houston, TX, USA
| | | | - Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Petros Grivas
- Division of Medical Oncology, Department of Medicine, University of Washington, 1144 Eastlake Ave E, LG-465, Seattle, WA, 98109, USA. .,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle, WA, 98109, USA. .,Seattle Cancer Care Alliance, 1144 Eastlake Ave E, LG-465, Seattle, WA, 98109, USA.
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114
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Tingry T, Massy E, Piperno M, Auroux M, Kostine M, Maillet D, Amini-Adle M, Fabien N, Estublier C, Goncalves D, Girard N, Confavreux CB. [Rheumatic immune adverse events related to immune checkpoint inhibitors-(IrAEs related to ICI)]. Bull Cancer 2021; 108:643-653. [PMID: 33902919 DOI: 10.1016/j.bulcan.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 12/17/2022]
Abstract
New anti-cancer therapeutics have been developed in the recent years and dramatically change prognosis and patient management. Either used alone or in combination, immune checkpoint inhibitors (ICI), such as anti-CTLA-4 and anti-PD1/PD-(L)1, act by removing T-cell inhibition to enhance their antitumor response. This change in therapeutic targets leads to a break in immune-tolerance and a unique toxicity profile resulting in immune complications. These side effects, called Immune-Related Adverse Events (IrAEs), can affect all organs, with a wide range of clinical and biological presentations and severity. Various rheumatic and musculoskeletal manifestations have been reported in the literature, ranging from mild arthralgia, polymyalgia rheumatica, to genuine serodefined rheumatoid arthritis and myositis. Tolerance studies suggest some correlations between IrAEs occurrence and tumor response. Assessment of patient musculoskeletal status prior to the start of the ICI is warranted. Management of rheumatic IrAEs does not usually request ICI discontinuation, exception for myositis or very severe forms where it should be discussed. Treatment relies on non-steroidal anti-inflammatory drugs (NSAIDs) or low dose glucocortioids (<20mg per day). Dose should be adjusted according to severity. The use of disease modifying anti-rheumatic drugs (DMARDs), either conventional and/or biological should be very cautious and result from a shared decision between oncologist and rheumatologist to best manage dysimmunitary complications without hampering the antitumor efficacy of ICI.
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Affiliation(s)
- Thomas Tingry
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Emmanuel Massy
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Muriel Piperno
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Maxime Auroux
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France
| | - Marie Kostine
- Centre hospitalier universitaire de Bordeaux, département de rhumatologie, 33000 Bordeaux, France
| | - Denis Maillet
- Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France; Centre Hospitalier Lyon Sud, Hospices civils de Lyon, service d'oncologie médicale, 69310 Pierre Bénite, France
| | - Mona Amini-Adle
- Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France; Centre de lutte contre le cancer Léon-Bérard, service de dermatologie, 69003 Lyon, France
| | - Nicole Fabien
- Centre Hospitalier Lyon Sud, hospices civils de Lyon, laboratoire d'auto-immunité, 69310 Pierre Bénite, France
| | - Charline Estublier
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - David Goncalves
- Centre Hospitalier Lyon Sud, hospices civils de Lyon, laboratoire d'auto-immunité, 69310 Pierre Bénite, France
| | - Nicolas Girard
- Institut Curie, institut du Thorax Curie Montsouris, 75005 Paris, France
| | - Cyrille B Confavreux
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France.
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Verspohl SH, Holderried T, Behning C, Brossart P, Schäfer VS. Prevalence, therapy and tumour response in patients with rheumatic immune-related adverse events following immune checkpoint inhibitor therapy: a single-centre analysis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211006963. [PMID: 33912248 PMCID: PMC8047846 DOI: 10.1177/1759720x211006963] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) improved cancer therapy by inducing a higher immune system activity. This effect can cause rheumatic immune-related adverse events (rh-irAEs), which have not yet been extensively studied. METHODS We analysed 437 patients between 2014 and 2019, treated with ipilimumab (anti-CTLA-4) and/or nivolumab (anti-PD-1) or pembrolizumab (anti-PD-1) at the Clinic for Internal Medicine III, Oncology, Haematology and Rheumatology at the University Hospital Bonn, Germany. RESULTS Of the 437 patients 60% were males. Patients were mainly treated for melanoma, lung cancer, head and neck tumour and urothelial carcinoma. At least one immune-related adverse event (irAE) was observed in 163 patients (37.3%), including rh-irAE. Most common side effects were rash, colitis and hepatitis. We identified 19 patients (4.3%) with a minimum of one rh-irAE due to ICI therapy; three of those had a pre-existing rheumatic disease. Arthralgia developed most frequently in eight patients (42.1%). Other rh-irAEs were: arthritis (n = 7; distinguished in rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis and undifferentiated arthritis), myalgia (n = 2) and myositis (n = 3). Most rh-irAEs were classified as moderately severe (Common Terminology Criteria of Adverse Events grade 2: 68.4%). Median time between starting ICI therapy and the occurrence of rh-irAE was 109 days (interquartile range 40-420 days). Fifteen patients (78.9%) were treated with glucocorticosteroids. In four cases additional therapy with methotrexate or tocilizumab was required. Even though patients benefited from ICI treatment, therapy had to be discontinued in six of the participants due to rh-irAE. Interestingly, patients with rh-irAE had a significantly higher tumour response compared with patients without rh-irAE (94.4% versus 43.5%; p < 0.0001). CONCLUSION Rh-irAEs occur under ICI therapy, especially in patients with higher tumour response. However, they are not the most frequent irAE after ICI exposure: 9.3% of all irAEs were rheumatic (20 rh-irAE cases in 19 patients of a total of 215 irAE cases in 163 patients).
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Affiliation(s)
- Sophia H. Verspohl
- Clinic for Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Bonn, Germany
| | - Tobias Holderried
- Clinic for Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Bonn, Germany
| | - Charlotte Behning
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Peter Brossart
- Clinic for Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Bonn, Germany
| | - Valentin S. Schäfer
- Clinic for Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Germany, Venusberg Campus 1, Bonn 53127, Germany
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Abstract
The proliferation of targeted anticancer agents over the last two decades has revolutionized cancer treatment and improved survival in many previously refractory malignancies. However, many agents are associated with characteristic ophthalmic adverse effects. It is important that ophthalmologists recognize and maintain a high index of suspicion for these side effects in patients on targeted therapy. Most ophthalmic adverse effects can be treated with specific ocular therapy without discontinuation of cancer treatment, although it is important to be aware of the life-threatening and vision-threatening circumstances that would require therapy cessation in conjunction with the patient's oncologist. This review aims to summarize the ophthalmic adverse effects of targeted and hormonal anticancer agents and briefly describe their management.
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117
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Roth P, Winklhofer S, Müller AMS, Dummer R, Mair MJ, Gramatzki D, Le Rhun E, Manz MG, Weller M, Preusser M. Neurological complications of cancer immunotherapy. Cancer Treat Rev 2021; 97:102189. [PMID: 33872978 DOI: 10.1016/j.ctrv.2021.102189] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/11/2022]
Abstract
Immunotherapy has emerged as a powerful therapeutic approach in many areas of clinical oncology and hematology. The approval of ipilimumab, a monoclonal antibody targeting the immune cell receptor CTLA-4, has marked the beginning of the era of immune checkpoint inhibitors. In the meantime, numerous antibodies targeting the PD-1 pathway have expanded the class of clinically approved immune checkpoint inhibitors. Furthermore, novel antibodies directed against other immune checkpoints are currently in clinical evaluation. More recently, bispecific antibodies, which link T cells directly to tumor cells as well as adoptive T cell transfer with immune cells engineered to express a chimeric antigen receptor, have been approved in certain indications. Neurological complications associated with the use of these novel immunotherapeutic concepts have been recognized more and more frequently. Immune checkpoint inhibitors may cause various neurological deficits mainly by alterations of the peripheral nervous system's integrity. These include radiculopathies, neuropathies, myopathies as well as myasthenic syndromes. Side effects involving the central nervous system are less frequent but may result in severe clinical symptoms and syndromes. The administration of chimeric antigen receptor (CAR) T cell is subject to rigorous patient selection and their use is frequently associated with neurological complications including encephalopathy and seizures, which require immediate action and appropriate therapeutic measures. Close clinical monitoring for neurological symptoms is key for early recognition of immunotherapy-related side effects. Comprehensive diagnostic work-up and adequate therapeutic measures are essential to avoid further clinical deterioration and residual neurological deficits.
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Affiliation(s)
- Patrick Roth
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland.
| | - Sebastian Winklhofer
- Department of Neuroradiology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Antonia M S Müller
- Department of Medical Oncology and Hematology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Maximilian J Mair
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Dorothee Gramatzki
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland; Department of Neurosurgery, University Hospital and University of Zurich, Zurich, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
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118
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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 PMCID: PMC7979511 DOI: 10.1016/j.cell.2021.02.011] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [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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Weill A, Delyon J, Descamps V, Deschamps L, Dinulescu M, Dupuy A, Célérier P, Nardin C, Aubin F, Le Corre Y, Heidelberger V, Maubec E, Malissen N, Longvert C, Machet L, Gounant V, Brosseau S, Bonniaud B, Jeudy G, Psimaras D, Doucet L, Lebbe C, Zalcman G, De Masson A, Baroudjian B, Leonard-Louis S, Hervier B, Brunet-Possenti F. Treatment strategies and safety of rechallenge in the setting of immune checkpoint inhibitors-related myositis: A national multicenter study. Rheumatology (Oxford) 2021; 60:5753-5764. [PMID: 33725115 DOI: 10.1093/rheumatology/keab249] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/04/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The occurrence of immune-related myositis (irM) is increasing, yet there are no therapeutic guidelines. We sought to analyze the current therapeutic strategies of irM and evaluate the outcomes of immune checkpoint inhibitors (ICI) rechallenge. METHODS We conducted a nationwide retrospective study between April 2018 and March 2020 including irM without myocardial involvement. Depending on the presence of cutaneous signs or unusual histopathological features, patients were classified into two groups: typical or atypical irM. Therapeutic strategies were analyzed in both groups. The modalities and outcomes of ICI rechallenge were reviewed. RESULTS Among the 20 patients, 16 presented typical irM. Regardless of severity, most typical irM were treated with steroid monotherapy (n = 14/16) and all had a complete response within ≤ 3 weeks. The efficacy of oral steroids for non-severe typical irM (n = 10) was the same with low-dose (≤ 0.5 mg/kg/day) or high-dose (1 mg/kg/day). Severe typical irM were successfully treated with intravenous methylprednisolone. Atypical irM (n = 4) had a less favorable evolution, including one irM-related death, and required heavy immunosuppression. ICI were safely reintroduced in 9 patients presenting a moderate (n = 6) or a severe (n = 3) irM. CONCLUSION Our data highlight that steroid monotherapy is an effective treatment for typical irM, either with prednisone or with intravenous methylprednisone pulses depending on the severity. The identification of unusual features is important in determining the initial therapeutic strategy. The outcomes of rechallenged patients are in favor of a safe reintroduction of ICI following symptom resolution and CK normalization in moderate and severe forms of irM.
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Affiliation(s)
- Amandine Weill
- Department of Dermatology, Hôpital Bichat, AP-HP, Université de Paris, Paris, France
| | - Julie Delyon
- Department of Dermatology, Hôpital Saint Louis, AP-HP, Université de Paris, Paris, France
| | - Vincent Descamps
- Department of Dermatology, Hôpital Bichat, AP-HP, Université de Paris, Paris, France
| | - Lydia Deschamps
- Department of Pathology, Hôpital Bichat, AP-HP, Université de Paris, Paris, France
| | - Monica Dinulescu
- Department of Dermatology, CHU de Rennes, Université de Rennes, Rennes, France
| | - Alain Dupuy
- Department of Dermatology, CHU de Rennes, Université de Rennes, Rennes, France
| | | | - Charlee Nardin
- Department of Dermatology, CHU de Besançon, Université de Franche Comté, Besançon, France
| | - François Aubin
- Department of Dermatology, CHU de Besançon, Université de Franche Comté, Besançon, France
| | - Yannick Le Corre
- Department of Dermatology, CHU d'Angers, Université LUNAM, Angers, France
| | - Valentine Heidelberger
- Department of Dermatology, Hôpital Avicenne, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Eve Maubec
- Department of Dermatology, Hôpital Avicenne, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Nausicaa Malissen
- Department of Dermatology, Hôpital La Timone, AP-HM, Université d'Aix-Marseille, Marseille, France
| | - Christine Longvert
- Department of Dermatology, Hôpital Ambroise-Paré, AP-HP, Boulogne-Billancourt, France
| | - Laurent Machet
- Dermatology Department, CHRU de Tours, Université de Tours, Tours, France
| | - Valérie Gounant
- Department of Thoracic Oncology, Hôpital Bichat, AP-HP, Université de Paris, Paris, France
| | - Solenne Brosseau
- Department of Thoracic Oncology, Hôpital Bichat, AP-HP, Université de Paris, Paris, France
| | - Bertille Bonniaud
- Department of Dermatology, Hôpital universitaire de Dijon, Dijon, France
| | - Géraldine Jeudy
- Department of Dermatology, Hôpital universitaire de Dijon, Dijon, France
| | - Dimitri Psimaras
- Department of Neurology, Hôpital La Pitié Salpétrière, AP-HP, Université Sorbonne Paris Centre, Paris, France
| | - Ludovic Doucet
- Department of Oncology, Hôpital Saint Louis, AP-HP, Université 7, Paris, France
| | - Céleste Lebbe
- Department of Dermatology, Hôpital Saint Louis, AP-HP, Université de Paris, Paris, France
| | - Gérard Zalcman
- Department of Thoracic Oncology, Hôpital Bichat, AP-HP, Université de Paris, Paris, France
| | - Adèle De Masson
- Department of Dermatology, Hôpital Saint Louis, AP-HP, Université de Paris, Paris, France
| | - Barouyr Baroudjian
- Department of Dermatology, Hôpital Saint Louis, AP-HP, Université de Paris, Paris, France
| | - Sarah Leonard-Louis
- Department of Neuropathology, Hôpital La Pitié Salpétrière, AP-HP, Université Sorbonne Paris Centre, Paris, France
| | - Baptiste Hervier
- Department of Internal Medicine, Hôpital Saint Louis, AP-HP, Université de Paris, Paris, France
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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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121
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Rheumatic and musculoskeletal disorders induced by immune checkpoint inhibitors: Consequences on overall survival. Joint Bone Spine 2021; 88:105168. [PMID: 33675979 DOI: 10.1016/j.jbspin.2021.105168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/10/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Immune checkpoint inhibitors (ICIs) frequently induce immune related adverse events (irAEs) that may be associated with more favorable clinical outcomes. We aimed to evaluate the impact of all types of rheumatic adverse events (AEs) on overall survival (OS) and tumor response in patients treated with ICIs. METHODS We performed a single-center retrospective observational study to analyze the OS and tumor response in patients receiving ICIs who experienced a rheumatic AE compared to those who did not experience any AE. RESULTS From December 2010 to September 2018, 264 patients with any cancer type were included. Forty-three patients (16.3%) presented with at least one rheumatic AE. The median OS of patients with rheumatic AEs was significantly higher than that of patients without AEs, with 132 weeks (95% CI [69.3-not reached]) and 42.7 weeks (95% CI [25.6-not reached]), respectively (P<0.01). This result remained significant after multivariate analysis (HR 0.54, 95% CI [0.30-0.97], P<0.05). Also, tumor response was better in patients with rheumatic AEs. CONCLUSION The occurrence of rheumatic AEs in patients treated with ICIs is associated with better survival and tumor response. Therefore, it seems essential to detect rheumatic AEs as early as possible to allow rapid and optimal management, given the long-term response potential of these patients.
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122
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Abstract
PURPOSE OF REVIEW This article reviews the clinical features, prognosis, and treatment of neurotoxicity from anticancer drugs, including conventional cytotoxic chemotherapy, biologics, and targeted therapies, with a focus on the newer immunotherapies (immune checkpoint inhibitors and chimeric antigen receptor T cells). RECENT FINDINGS Whereas neurologic complications from traditional chemotherapy are widely recognized, newer cancer therapies, in particular immunotherapies, have unique and distinct patterns of neurologic adverse effects. Anticancer drugs may cause central or peripheral nervous system complications. Neurologic complications of therapy are being seen with increasing frequency as patients with cancer are living longer and receiving multiple courses of anticancer regimens, with novel agents, combinations, and longer duration. Neurologists must know how to recognize treatment-related neurologic toxicity since discontinuation of the offending agent or dose adjustment may prevent further or permanent neurologic injury. It is also imperative to differentiate neurologic complications of therapy from cancer progression into the nervous system and from comorbid neurologic disorders that do not require treatment dose reduction or discontinuation. SUMMARY Neurotoxicity from cancer therapy is common, with effects seen on both the central and peripheral nervous systems. Immune checkpoint inhibitor therapy and chimeric antigen receptor T-cell therapy are new cancer treatments with distinct patterns of neurologic complications. Early recognition and appropriate management are essential to help prevent further neurologic injury and optimize oncologic management.
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123
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MHC class I loss in endometrial carcinoma: a potential resistance mechanism to immune checkpoint inhibition. Mod Pathol 2021; 34:627-636. [PMID: 33011747 DOI: 10.1038/s41379-020-00682-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 11/08/2022]
Abstract
Major histocompatibility complex (MHC) class I is a membrane-bound protein complex expressed on nucleated human cells. MHC class I presents intracellular protein fragments to cytotoxic T cells and triggers an activation cascade upon neoantigen detection by these cells. MHC class I loss by tumor cells decreases tumor neoantigen presentation to the immune system and therefore represents a possible mechanism of immunotherapeutic resistance even among cancers that otherwise appear to be good candidates for checkpoint inhibition, such as mismatch repair (MMR)-deficient and PD-L1-positive malignancies. We herein assess MHC class I expression in a range of endometrial carcinomas, including MMR-deficient and PD-L1-positive cancers. Immunohistochemical staining for combined MHC class I A-, B-, and C-heavy chains was performed on 76 cases of endometrial carcinoma and was classified as present, subclonally lost, or diffusely lost. Tumoral PD-L1 expression, PD-L1 combined positive score, and CD3-positive T lymphocytes were also quantified. Forty-two percent of tumors showed loss of MHC class I expression, either in a subclonal (26%) or diffuse (16%) pattern. This included 46% of MMR-deficient and 25% of PD-L1-positive cancers. These findings suggest that tumoral MHC class I status may be an important factor to consider when selecting endometrial cancer patients for checkpoint inhibition.
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124
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Bax CE, Maddukuri S, Ravishankar A, Pappas-Taffer L, Werth VP. Environmental triggers of dermatomyositis: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:434. [PMID: 33842655 PMCID: PMC8033368 DOI: 10.21037/atm-20-3719] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Dermatomyositis (DM) is an autoimmune disease that affects the skin, lungs, and muscle. Although the pathogenesis of DM is not completely understood, several environmental triggers have been linked to DM onset or flare. This article specifically examines the effects of herbal supplements, drugs, infections, ultraviolet (UV) radiation, and environmental pollutants on the onset or exacerbation of DM. Herbal supplements such as Spirulina platensis, Aphanizomenon flos-aquae, Chlorella, Echinacea, and Alfalfa have been implicated and are frequently used in health foods. Medications such as hydroxyurea, TNF-α inhibitors, immune checkpoint inhibitors (ICI), and penicillamine, as well as certain viral infections, such as parvovirus B19, coxsackie virus, polyomavirus, Epstein-Barr virus (EBV), hepatitis, influenza, and human immunodeficiency viruses (HIV) have been associated with DM onset. Bacterial infections and vaccinations have also been linked to the development of DM. Additional environmental factors, including UV radiation and air pollutants, such as silica, biological/mineral dust, and particulate air matter from vehicle and industrial emissions, may also play a role in DM pathogenesis. Overall, there is general agreement that an autoimmune attack of the skin, muscle, and lungs in DM can be triggered by various environmental factors and warrants further investigation.
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Affiliation(s)
- Christina E Bax
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Spandana Maddukuri
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Adarsh Ravishankar
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa Pappas-Taffer
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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125
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Abstract
Immune checkpoint inhibitors activate the immune system to combat cancer. In doing so, however, they can cause immune-related adverse events (irAEs), including rheumatic syndromes, such as inflammatory arthritis, polymyalgia rheumatica, and myositis. This article reviews rheumatic irAEs that may be encountered in the general medicine practice and provides guidance to support prompt recognition, referral, and treatment of these patients.
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Affiliation(s)
- Nilasha Ghosh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Anne R Bass
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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126
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Xu Y, Wen N, Sonis ST, Villa A. Oral side effects of immune checkpoint inhibitor therapy (ICIT): An analysis of 4683 patients receiving ICIT for malignancies at Massachusetts General Hospital, Brigham & Women's Hospital, and the Dana-Farber Cancer Institute, 2011 to 2019. Cancer 2021; 127:1796-1804. [PMID: 33595843 DOI: 10.1002/cncr.33436] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are increasingly accepted as a treatment option for several cancers. Although various systemic immune-related adverse events (irAEs) have been characterized, the effect of ICIs on the oral cavity and contiguous structures is still poorly understood. METHODS Electronic medical records of 4683 patients in the Mass General Brigham Registered Patient Data Registry who received ICI therapy (ICIT) between December 2011 and September 2019 were reviewed. Reports of oral conditions were categorized into oral mucosal disorders, xerostomia, and dysgeusia. After applying exclusion criteria, demographic characteristics and clinical features were summarized for the patients who had oral irAEs. RESULTS In total, 317 patients developed oral conditions that were associated with ICIT (incidence, 6.8%; 317 of 4683 patients). These conditions included xerostomia (68.5%), oral mucosal disorders (33.4%), and dysgeusia (24.0%). In patients with oral irAEs, respiratory cancer (28.4%) was the most common primary cancer, followed by melanoma (26.2%), and head and neck cancer (14.8%). Oral mucosal disorders developed after the initiation of ICIT between 2 and 851 days (between 1 and 1332 days in patients with xerostomia and between 1 and 1455 days in patients with dysgeusia). Of all oral irAEs, 50.9% developed within 3 months, and 85.5% developed within 12 months. CONCLUSIONS Oral side effects appear to be more common among patients who receive ICIT than has been previously reported. Concomitant cytotoxic regimens may exacerbate the risk of oral adverse events, perhaps representing the sum of the effects of different, but simultaneous or sequential, pathogenic mechanisms. Additional studies are warranted to better characterize oral irAEs and their biologic basis.
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Affiliation(s)
- Yuanming Xu
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard School of Dental Medicine, Boston, Massachusetts
| | - Natalie Wen
- Harvard School of Dental Medicine, Boston, Massachusetts
| | - Stephen T Sonis
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard School of Dental Medicine, Boston, Massachusetts
| | - Alessandro Villa
- Department of Orofacial Sciences, University of California, San Francisco, California
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127
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Zhang S, Zhou Z, Wang L, Li M, Zhang F, Zeng X. Rheumatic immune-related adverse events associated with immune checkpoint inhibitors compared with placebo in oncologic patients: a systemic review and meta-analysis. Ther Adv Chronic Dis 2021; 12:2040622320976996. [PMID: 33633822 PMCID: PMC7887685 DOI: 10.1177/2040622320976996] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/06/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE We aim to characterize the incidence and relative risk of rheumatic and systemic immune-related adverse effects (irAEs) among immune checkpoint inhibitor (ICI) therapy compared with those after placebo treatment. METHODS Randomized clinical trial studies with placebo control with the following keywords were searched from Embase, PubMed, Cochrane databases: immune checkpoint inhibitors, neoplasms, randomized controlled trials, and adverse effects. RESULTS Among the 5444 published and 316 registration records, nine placebo-controlled randomized clinical trials met our selection criteria, and included data from 5560 patients. Compared with placebo use, using ICIs increases the risk of overall-rheumatic irAEs. The incidence and relative risk of all-grade rheumatic irAEs were 18.40% [95% confidence interval (CI) 12.16-25.59%, p < 0.01] and 2.30 (95% CI 1.32-4.02), respectively, while musculoskeletal irAEs were 11.30% (95% CI 9.76-12.85%) and 1.01 (95% CI 0.84-1.22). The incidence and relative risk of severe rheumatic irAEs were 5.72% (95% CI 3.92-7.82%), and 8.29 (95% CI 3.75-18.35), respectively. Arthralgia was the most common rheumatic irAE (incidence 11.00%, 95% CI 9.55-12.64%; relative risk 0.99, 95% CI 0.82-1.19), although usually not severe. Colitis (incidence 3.23%, 95% CI 1.27-7.98%; relative risk 6.53, 95% CI 2.66-16.04) and pneumonitis (incidence 3.11%, 95% CI 1.56-6.21; relative risk 4.04, 95% CI 1.65-9.89) were commonly observed and tended to be severe. Hepatitis, hypophysitis, thyroiditis, and myositis were rare and less recorded, yet can be severe and life threatening. Other extremely rare severe rheumatic irAEs included sarcoidosis (n = 11), autoimmune arthritis (n = 8), autoimmune uveitis (n = 3), autoimmune pericarditis, bursitis, osteochondrosis, psoriasis, polymyalgia rheumatica, systemic inflammatory response syndrome, and Sjögren syndrome (n = 1, each). CONCLUSION ICI therapy increased the incidence and relative risk of all-grade and severe rheumatic irAEs. Arthralgia was the most commonly observed non-severe irAE, while colitis and pneumonitis were commonly observed severe irAEs. Rare rheumatic irAEs like hepatitis, hypophysitis, thyroiditis, and myositis warrant special attention.
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Affiliation(s)
- Shuo Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ziyue Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1, Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Abstract
PURPOSE OF REVIEW This review summarizes the current evidence on treatment strategies for inflammatory arthritis because of cancer treatment with immune checkpoint inhibitors (ICI), prognosis of ICI-induced arthritis, and management of patients with preexisting inflammatory arthritis receiving ICI therapy. RECENT FINDINGS Inflammatory arthritis is the most common rheumatic immune-related adverse event observed in patients receiving ICI therapy. Most patients can successfully be treated with low doses of corticosteroids or conventional synthetic disease modifying anti-rheumatic drugs (DMARDs). A small minority will develop severe symptoms requiring biologic therapy including TNF inhibitors and IL-6 receptor inhibitors. Many cases of inflammatory arthritis will resolve with cessation of ICI therapy. Some patients will develop persistent arthritis despite discontinuation. Patients with preexisting inflammatory arthritis (e.g. rheumatoid arthritis) commonly flare on ICI therapy, but can usually be managed with corticosteroids. SUMMARY Inflammatory arthritis following ICI therapy for cancer is relatively common and the practicing rheumatologist should be able to recognize and manage it in conjunction with Oncology. The majority of patients respond to corticosteroids, but some will need treatment with conventional synthetic or biologic DMARDs. Additional studies should investigate the effects of immunosuppression on tumor response and the use of ICI therapy in patients with preexisting autoimmune disease.
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Rivet V, Quantin X, Faillie JL, Lesage C, Meunier L, Faure S, Hillaire-Buys D, Lesouder C, Fabre S, Assenat E, Rullier P, Guilpain P, Maria ATJ. [Management of immune-related toxicities associated with immune checkpoints inhibitors: Data from the multidisciplinary meeting « ToxImmun » in Eastern Occitania]. Rev Med Interne 2021; 42:310-319. [PMID: 33485701 DOI: 10.1016/j.revmed.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 12/06/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
Immune checkpoint inhibitors (ICIs) can cause numerous and complex immune-related adverse events whose management need a multidisciplinary approach. Herein, we investigated 114 requests, mostly concerning patients suffering from lung cancer, that were submitted to the « ToxImmun » multidisciplinary meeting in Eastern Occitania between December the 17th 2018 and January the 20th 2020. The leading reasons for the request concerned the putative causal link between immunotherapy and immune-toxicity and its management, followed by possible retreatment after temporary withdrawn because of adverse event, and finally the possibility to initiate ICIs in patients with pre-existing autoimmunity. Colitis, hepatitis and myocarditis were the most frequent immune-related adverse events (IRAEs), both all grade and grade 3-4. Sicca syndrome (with or without Sjogren criteria) was also frequent (26% of cases) and seems to be associated with severe toxicity and multi-toxicity. The mean time to first IRAE was 3.8 months, a time shortened with the use of anti-PD-L1 agents or ICI combination. A majority of requests came from initial evaluation by the internist confirming the early and main role of this specialty in the management of immunotoxicity. Expansion of this regional multidisciplinary meeting, coordinated by internists and medical oncologists, could improve management of immune-related adverse events for the patients' benefits.
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Affiliation(s)
- V Rivet
- Service de médecine interne : maladies multi-organiques de l'adulte, hôpital Saint-Éloi, CHRU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Faculté de médecine, université de Montpellier, Montpellier, France
| | - X Quantin
- Faculté de médecine, université de Montpellier, Montpellier, France; Service d'oncologie médicale-oncologie thoracique, institut du cancer de Montpellier, Val d'Aurelle, Montpellier, France
| | - J L Faillie
- Faculté de médecine, université de Montpellier, Montpellier, France; Département de pharmacologie médicale et toxicologie, centre régional de pharmacovigilance, hôpital Lapeyronie, CHRU de Montpellier, Montpellier, France
| | - C Lesage
- Service de dermatologie clinique, hôpital Saint-Éloi, CHRU de Montpellier, Montpellier, France
| | - L Meunier
- Faculté de médecine, université de Montpellier, Montpellier, France; Service d'hépato-gastro-entérologie, hôpital Saint-Éloi, CHRU de Montpellier, Montpellier, France
| | - S Faure
- Service d'hépato-gastro-entérologie, hôpital Saint-Éloi, CHRU de Montpellier, Montpellier, France
| | - D Hillaire-Buys
- Faculté de médecine, université de Montpellier, Montpellier, France; Département de pharmacologie médicale et toxicologie, centre régional de pharmacovigilance, hôpital Lapeyronie, CHRU de Montpellier, Montpellier, France
| | - C Lesouder
- Département de pharmacologie médicale et toxicologie, centre régional de pharmacovigilance, hôpital Lapeyronie, CHRU de Montpellier, Montpellier, France
| | - S Fabre
- Service de médecine interne, clinique Beau-Soleil, Montpellier, France
| | - E Assenat
- Faculté de médecine, université de Montpellier, Montpellier, France; Service d'oncologie médicale, hôpital Saint-Éloi, CHRU de Montpellier, Montpellier, France
| | - P Rullier
- Service de médecine interne : maladies multi-organiques de l'adulte, hôpital Saint-Éloi, CHRU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - P Guilpain
- Service de médecine interne : maladies multi-organiques de l'adulte, hôpital Saint-Éloi, CHRU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Faculté de médecine, université de Montpellier, Montpellier, France; IRMB Institute for regenerative medicine and biotherapy, Inserm U1183, hôpital Saint-Éloi, Montpellier, France
| | - A T J Maria
- Service de médecine interne : maladies multi-organiques de l'adulte, hôpital Saint-Éloi, CHRU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Faculté de médecine, université de Montpellier, Montpellier, France; IRMB Institute for regenerative medicine and biotherapy, Inserm U1183, hôpital Saint-Éloi, Montpellier, France.
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130
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Alba-Linero C, Alba E. Ocular side effects of checkpoint inhibitors. Surv Ophthalmol 2021; 66:951-959. [PMID: 33440195 DOI: 10.1016/j.survophthal.2021.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 01/06/2023]
Abstract
The incidence and impact of ocular side effects in patients treated with checkpoint inhibitors are not clearly defined. We reviewed prospective phase III clinical trials of checkpoint inhibitors applied in lung cancer, renal cell cancer, and melanoma. Case reports of the occurrence of ocular toxicities in patients receiving immune checkpoint inhibitors were also included. Of the 35 articles corresponding to phase III clinical trials with checkpoint inhibitors, ocular toxicity was described in four. Forty-six clinical cases of ocular toxicity after therapy with checkpoint inhibitors have been reported. The most frequently described ocular toxicities are uveitis, inflammatory orbital disease, and alterations of the ocular surface. Ocular toxicity is underestimated in checkpoint inhibitors clinical trials. Early ophthalmic examination and treatment with corticosteroids may improve the visual prognosis in these patients.
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Affiliation(s)
- Carmen Alba-Linero
- Hospital Regional Universitario Málaga, Málaga, Spain; Departamento Oftalmología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain.
| | - Emilio Alba
- Unidad de gestión clínica (UGI) Oncología Médica Hospital Regional y Universitario de Málaga, Instituto de Investigación de Biotecnología de Málaga (IBIMA), Málaga, Spain
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131
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Czarnecka AM, Rutkowski P. An update on the safety of nivolumab for the treatment of advanced melanoma. Expert Opin Drug Saf 2021; 19:409-421. [PMID: 32293935 DOI: 10.1080/14740338.2020.1757068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Due to its unique mechanism of action as an immune checkpoint inhibitor, nivolumab has high antitumor activity, but at the same time this mechanism is responsible for immune-related adverse events that may limit patients' safety and therapy continuation.Areas covered: Long-term safety of nivolumab including 5-year follow-up, safety of nivolumab treatment after ipilimumab therapy, safety of nivolumab in challenging subgroups (elderly, patients with brain metastases, patients with autoimmune disorders), safety of nivolumab in with rare melanoma subtypes (including mucosal melanoma), as well as specificity of AEs reported for nivolumab treatment in melanoma patients in comparison to other cancer types and other immunotherapy molecules, and impact of AEs on response rates and PFS on nivolumab treatment are discussed.Expert opinion: Search for biomarkers that would help us to identify patient populations that may suffer from severe nivolumab toxicity could help in selecting patients that should not be treated with this type of therapy. Novel combinations and immunotherapy drugs including use of NKTR-214 (IL-2 pathway), lymphocyte-activation gene 3 (LAG-3), local injections of talimogene laherparepvec (T-VEC), or systemic use of T-cell receptors agonists such as OX40, CD137, ICOS-1, could provide regimens with limited toxicity and higher activity.
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Affiliation(s)
- Anna M Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland.,Department of Experimental Pharmacology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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132
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Spectrum and Management of Immune Related Adverse Events Due to Immune Checkpoint Inhibitors. Lung Cancer 2021. [DOI: 10.1007/978-3-030-74028-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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133
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Riveiro-Barciela M, Trallero-Araguás E, Martínez-Valle F. Toxicities from immunotherapy: From clinical trials to real-world clinical practice. Med Clin (Barc) 2020; 155:541-547. [PMID: 32868034 DOI: 10.1016/j.medcli.2020.06.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 02/07/2023]
Abstract
In recent years, immunotherapy has become an important pillar of cancer treatment, with high response rates regardless of tumour histology or baseline mutations. However, immune activation associated with check-point inhibitors is not selective and a large variety of immune-related adverse events have been associated with anti-PD1, anti-PD-1/L-1 and anti-CTLA-4 agents. Though diagnosis and treatment of these toxicities have been established according to the recommendations from clinical trials and in line with the autoimmune disorders that they mimic, increasing real-world data is coming up showing that these adverse events may have differential characteristics and management, especially in terms of the use of corticoids, second-line treatments, salvage therapy for life-threatening cases and reintroduction of immunotherapy. Herein we present a comprehensive review of current recommendations and real-world data on the main immune-related adverse events of immunotherapy.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Fernando Martínez-Valle
- Systemic Autoimmune Diseases Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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134
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Costa LB, Queiroz MA, Barbosa FG, Nunes RF, Zaniboni EC, Ruiz MM, Jardim D, Gomes Marin JF, Cerri GG, Buchpiguel CA. Reassessing Patterns of Response to Immunotherapy with PET: From Morphology to Metabolism. Radiographics 2020; 41:120-143. [PMID: 33275541 DOI: 10.1148/rg.2021200093] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cancer demands precise evaluation and accurate and timely assessment of response to treatment. Imaging must be performed early during therapy to allow adjustments to the course of treatment. For decades, cross-sectional imaging provided these answers, showing responses to the treatment through changes in tumor size. However, with the emergence of immune checkpoint inhibitors, complex immune response patterns were revealed that have quickly highlighted the limitations of this approach. Patterns of response beyond tumor size have been recognized and include cystic degeneration, necrosis, hemorrhage, and cavitation. Furthermore, new unique patterns of response have surfaced, like pseudoprogression and hyperprogression, while other patterns were shown to be deceptive, such as unconfirmed progressive disease. This evolution led to new therapeutic evaluation criteria adapted specifically for immunotherapy. Moreover, inflammatory adverse effects of the immune checkpoint blockade were identified, many of which were life threatening and requiring prompt intervention. Given complex concepts like tumor microenvironment and novel therapeutic modalities in the era of personalized medicine, increasingly sophisticated imaging techniques are required to address the intricate patterns of behavior of different neoplasms. Fluorine 18-fluorodeoxyglucose PET/CT has rapidly emerged as one such technique that spans both molecular biology and immunology. This imaging technique is potentially capable of identifying and tracking prognostic biomarkers owing to its combined use of anatomic and metabolic imaging, which enables it to characterize biologic processes in vivo. This tailored approach may provide whole-body quantification of the metabolic burden of disease, providing enhanced prediction of treatment response and improved detection of adverse events. ©RSNA, 2020.
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Affiliation(s)
- Larissa B Costa
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Marcelo A Queiroz
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Felipe G Barbosa
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Rafael F Nunes
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Elaine C Zaniboni
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Mariana Mazo Ruiz
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Denis Jardim
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Jose Flavio Gomes Marin
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Giovanni G Cerri
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
| | - Carlos A Buchpiguel
- From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.)
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135
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De Keukeleire S, Vermassen T, De Schoenmakere G, Kruse V, Vermaelen K, Rottey S. To treat or not to treat? Managing comorbidities in cancer patients under immune checkpoint inhibition. Acta Clin Belg 2020; 75:434-441. [PMID: 31357914 DOI: 10.1080/17843286.2019.1646516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Objectives: Assessing the safety and efficacy of immune checkpoint inhibition in risky cancer patient subgroups: pre-existing organ failure, elderly, presence of auto-immune disease, transplanted patients and brain metastasis treated with immune checkpoint inhibitors. Methods: PubMed, Web of Science and Google scholar databases were searched for English articles published prior to February 2019. Search terms used were organ failure, dialysis, elderly, organ transplant, liver disease, auto-immune disease, immunosuppression, and brain metastasis. Results: Our literature data indicate that immune checkpoint inhibition in the majority of these subpopulations can be administered safely without any loss of efficacy. These data are mostly based on case-reports as only a minority of high-risk patients were included in (the earliest) clinical trials. Validation of these results is necessary on a larger scale. Conclusion: Future trials should not automatically exclude aforementioned patient groups but alter the study design and make their inclusion possible, since more data are needed to answer several remaining questions in these populations. Especially since ICI appears to be safe to administer in these patients.
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Affiliation(s)
| | - Tijl Vermassen
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
- Drug Research Unit Ghent, Ghent University Hospital, Ghent, Belgium
| | | | - Vibeke Kruse
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Karim Vermaelen
- Department of Lung Diseases-Thoracic Oncology, Ghent University Hospital, Ghent, Belgium
| | - Sylvie Rottey
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
- Drug Research Unit Ghent, Ghent University Hospital, Ghent, Belgium
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136
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Cappelli LC, Bingham CO. Expert Perspective: Immune Checkpoint Inhibitors and Rheumatologic Complications. Arthritis Rheumatol 2020; 73:553-565. [PMID: 33186490 DOI: 10.1002/art.41587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
Rheumatologists increasingly receive consults for patients treated with immune checkpoint inhibitors (ICIs) for cancer. ICIs can cause inflammatory syndromes known as immune-related adverse events (IRAEs). Several rheumatic IRAEs have been reported, including inflammatory arthritis, polymyalgia rheumatica, and myositis. For patients who present with musculoskeletal symptoms while receiving ICI therapy, it is important to have an algorithm for evaluation. The differential diagnosis includes a range of musculoskeletal syndromes, such as crystalline arthritis, mechanical issues, and osteoarthritis, in addition to IRAEs. After diagnosing a rheumatic IRAE, rheumatologists must work with the patient and the oncologist to form a treatment plan. Treatment of IRAEs is guided by severity. Evidence for management is limited to observational studies. Inflammatory arthritis and polymyalgia rheumatica are treated with nonsteroidal antiinflammatory drugs in mild cases, glucocorticoids for moderate-to-severe cases, and sometimes require other disease-modifying antirheumatic drugs. Myositis due to ICIs can be accompanied by myocarditis or myasthenia gravis. Glucocorticoids and withholding the ICI are usually required to treat myositis; some patients with severe myositis require intravenous immunoglobulin or plasmapheresis. Further research is needed to optimize treatment of IRAEs that does not compromise the antitumor effect of ICIs.
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137
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Pagkopoulou E, Simopoulou T, Maragkouli E, Perifanou-Sotiri S, Kotsakis A, Bogdanos DP. Arthritis and Myositis in a Patient Treated with Programmed Cell Death-1 (PD-1) Inhibitor Pembrolizumab for Lung Cancer. Mediterr J Rheumatol 2020; 31:355-357. [PMID: 33163870 PMCID: PMC7641028 DOI: 10.31138/mjr.31.3.355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/17/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a new class of drug that have demonstrated efficacy across many cancer types. Because of their nature and mode of action, ICIs unleash immune activation raising concerns as to whether they can be used in patients with concomitant autoimmune or auto-inflammatory diseases. Their usage can lead to the development of autoimmune phenomena known as immune related adverse events (irAEs), virtually affecting every organ. As the use of ICIs is drastically increasing, evidence of irAEs has been accumulating. Herein, we report a case of inflammatory myositis and arthritis 6 months after pembrolizumab therapy, an anti-programmed death-1 (PD1) ICI in a patient with lung cancer, aiming at raising awareness of the diagnostic and clinical challenges clinicians may face when checkpoint inhibitors-related rheumatologic irAEs are developed.
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Affiliation(s)
| | | | - Eleni Maragkouli
- Department of Oncology, University General Hospital of Larissa, School of Health Sciences University of Thessaly, Larissa, Greece
| | | | - Athanasios Kotsakis
- Department of Oncology, University General Hospital of Larissa, School of Health Sciences University of Thessaly, Larissa, Greece
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138
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Dey A, Manolios N, Long GV, Carlino MS, Kefford R, Schrieber L. Musculoskeletal immune-related adverse events with the use of checkpoint inhibitors in malignancy. Intern Med J 2020; 52:818-827. [PMID: 33135853 DOI: 10.1111/imj.15123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Immunotherapy has revolutionised the treatment of many malignancies. Along with their success, there have been inflammatory and immune-related adverse events (irAE). There is a paucity of literature describing the Australian experience of rheumatic irAE. AIMS To describe and characterise the Royal North Shore Hospital and Westmead Hospital cohort with rheumatic irAE. METHODS This case series reports on 17 patients with advanced cancer treated at two sites in Sydney, Australia who were referred for rheumatological evaluation from 2013 to 2016. Data were collected retrospectively and inspected for clinical signs, duration of immunotherapy prior to onset of symptoms, management strategies and cancer outcomes. RESULTS Patients presented with arthralgias, myalgias, periarticular and systemic symptoms. Onset of rheumatological symptoms was variable, with a median of 4 months (range 0.2-24) for monotherapy and 5.05 months (range 0.2-6.9) for combination. The predominant findings were of tenosynovitis (23%) and large joint involvement (65%). All patients were seronegative for RF and anti-CCP. Most patients responded well to non-steroidal anti-inflammatory drugs or low-dose prednisone (59%) and remained on immunotherapy (77%). The majority (76%) of patients experienced concomitant irAE in other organ systems. Sixty-five percent of patients had complete response of their malignancy to immunotherapy. CONCLUSION Rheumatic irAE are heterogenous clinical entities, which require further evaluation into classification, patient susceptibility and response. From our study, there was no clear clinical pattern. The present case series supports that rheumatic irAE may be associated with tumour response. However, there is still limited experience in rheumatic irAE management and outcomes.
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Affiliation(s)
- Abhishikta Dey
- Department of Rheumatology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nicholas Manolios
- Department of Rheumatology, Westmead Hospital and; Professor of Rheumatology, Faculty of Medicine and Health University of Sydney, The University of Sydney, Sydney, New South Wales, Australia
| | - Georgina V Long
- Department of Oncology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Melanoma Institute Australia, Sydney, New South Wales, Australia
| | - Matteo S Carlino
- Melanoma Institute Australia, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Richard Kefford
- Melanoma Institute Australia, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Leslie Schrieber
- Department of Rheumatology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia
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139
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Henderson D, Eslamian G, Poon D, Crabb S, Jones R, Sankey P, Kularatne B, Linch M, Josephs D. Republished: Immune checkpoint inhibitor induced large vessel vasculitis. Drug Ther Bull 2020; 59:29-31. [PMID: 33093074 DOI: 10.1136/dtb.2020.233496rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Daisy Henderson
- Department of Palliative Care, Royal Free London NHS Foundation Trust, London, UK
| | - Gelareh Eslamian
- Department of Medical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Daniel Poon
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Crabb
- Cancer Sciences Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Robert Jones
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Peter Sankey
- Department of Clinical Oncology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Bihani Kularatne
- Department of Medical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Linch
- Department of Oncology, University College London Cancer Institute, London, UK
| | - Debra Josephs
- Department of Medical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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140
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Salamaliki C, Solomou EE, Liossis SNC. Immune Checkpoint Inhibitor-Associated Scleroderma-Like Syndrome: A Report of a Pembrolizumab-Induced "Eosinophilic Fasciitis-Like" Case and a Review of the Literature. Rheumatol Ther 2020; 7:1045-1052. [PMID: 33067734 PMCID: PMC7695772 DOI: 10.1007/s40744-020-00246-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/08/2020] [Indexed: 12/20/2022] Open
Abstract
Immune checkpoint inhibitors are a promising new therapeutic strategy in oncology that aims to eliminate cancer cells by enhancing patients' immune response against tumor antigens. Despite their beneficial effects, immune checkpoint inhibitors are also responsible for a plethora of autoimmune manifestations, known as immune-related adverse events. We present a case of eosinophilic fasciitis-like disorder in an 81-year-old patient treated with the programmed death cell protein 1 inhibitor pembrolizumab for non-small-cell lung cancer. The patient developed characteristic indurated skin lesions in his limbs after 1½ years of treatment with pembrolizumab and a typical “groove sign.” Raynaud’s syndrome was absent. A full-thickness biopsy confirmed the clinical diagnosis of an “EF-like” condition. Neither peripheral eosinophilia nor eosinophilic infiltrates in the skin biopsy were found. His symptoms improved after a 2.5-month CPI discontinuation and treatment with 16 mg of methylprednisolone slowly tapered to a dose of 4 mg. Eosinophilic fasciitis is a rare immune-related adverse event of CPI treatment; our literature search identified only 12 cases that fulfill the criteria of EF in patients receiving CPIs.
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Affiliation(s)
- Christina Salamaliki
- Division of Rheumatology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Elena E Solomou
- Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Stamatis-Nick C Liossis
- Division of Rheumatology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece.
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141
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Benesova K, Leipe J. Nebenwirkungen immunonkologischer Therapien. AKTUEL RHEUMATOL 2020. [DOI: 10.1055/a-1209-0659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungImmunonkologische Therapien und insbesondere die Immuncheckpoint-Inhibitoren (ICPi) als Hauptvertreter dieser neuen Substanzklasse kommen bei zunehmender Anzahl von soliden und teils auch hämatologischen Tumorentitäten und Indikationen zum Einsatz. Die relativ hohen (Langzeit-)Tumoransprechraten auch in fortgeschrittenen und therapierefraktären Stadien haben die therapeutischen Möglichkeiten der Onkologie geradezu revolutioniert. Gleichzeitig bringt der zunehmende Einsatz von ICPi auch neue Herausforderungen: Immunonkologische Therapien verursachen ein breites Spektrum an autoimmunen Nebenwirkungen, sogenannten „immune-related adverse events“ (irAEs), die teilweise klassischen Autoimmunopathien ähneln und jedes Organsystem betreffen können. Die große Mehrheit der ICPi-behandelten Patienten erlebt ein irAE an mindestens einem Organsystem und davon weisen ca. 5–20% ein rheumatisches irAEs auf. Diese sind interessanterweise mit einem besseren Tumoransprechraten bei ICPi-Therapie assoziiert und können entweder die Erstmanifestation einer klassischen entzündlich-rheumatischen Erkrankung oder auch nur eine transiente Nebenwirkung mit spezifischen Charakteristika sein. Zweifelsohne wird das interdisziplinäre Management immunvermittelter Nebenwirkungen auch den Rheumatologen in den nächsten Jahren zunehmend beschäftigen. Der vorliegende Artikel fasst die Erkenntnisse zum klinischen Management von irAEs für den praktizierenden Rheumatologen zusammen.
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Affiliation(s)
- Karolina Benesova
- Sektion Rheumatologie, Abteilung Innere Medizin V Hämatologie Onkologie Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg
| | - Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München Medizinische Fakultät, München
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142
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Calabrese LH, Caporali R, Blank CU, Kirk AD. Modulating the wayward T cell: New horizons with immune checkpoint inhibitor treatments in autoimmunity, transplant, and cancer. J Autoimmun 2020; 115:102546. [PMID: 32980229 DOI: 10.1016/j.jaut.2020.102546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 09/02/2020] [Accepted: 09/14/2020] [Indexed: 12/20/2022]
Abstract
The T-cell response is regulated by the balance between costimulatory and coinhibitory signals. Immune checkpoints are essential for efficient T-cell activation, but also for maintaining self-tolerance and protecting tissues from damage caused by the immune system, and for providing protective immunity. Modulating immune checkpoints can serve diametric goals, such that blocking a coinhibitory molecule can unleash anti-cancer immunity whereas stimulating the same molecule can reduce an over-reaction in autoimmune disease. The purpose of this review is to examine the regulation of T-cell costimulation and coinhibition, which is central to the processes underpinning autoimmunity, transplant rejection and immune evasion in cancer. We will focus on the immunomodulation agents that regulate these unwanted over- and under-reactions. The use of such agents has led to control of symptoms and slowing of progression in patients with rheumatoid arthritis, reduced rejection rates in transplant patients, and prolonged survival in patients with cancer. The management of immune checkpoint inhibitor treatment in certain challenging patient populations, including patients with pre-existing autoimmune conditions or transplant patients who develop cancer, as well as the management of immune-related adverse events in patients receiving antitumor therapy, is examined. Finally, the future of immune checkpoint inhibitors, including examples of emerging targets that are currently in development, as well as recent insights gained using new molecular techniques, is discussed. T-cell costimulation and coinhibition play vital roles in these diverse therapeutic areas. Targeting immune checkpoints continues to be a powerful avenue for the development of agents suitable for treating autoimmune diseases and cancers and for improving transplant outcomes. Enhanced collaboration between therapy area specialists to share learnings across disciplines will improve our understanding of the opposing effects of treatments for autoimmune disease/transplant rejection versus cancer on immune checkpoints, which has the potential to lead to improved patient outcomes.
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Affiliation(s)
| | - Roberto Caporali
- University of Milan, Department of Clinical Sciences and Community Health and Rheumatology Division, ASST Pini-CTO Hospital, Milan, Italy
| | | | - Allan D Kirk
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
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143
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Immune Related Adverse Events: Classification and Management Approaches in Advanced Kidney Cancer. ACTA ACUST UNITED AC 2020; 26:432-440. [PMID: 32947311 DOI: 10.1097/ppo.0000000000000473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Recent therapeutic advancements have incorporated immune checkpoint inhibitors (ICIs) into the management of metastatic renal cell carcinoma. Pivotal phase III trials have resulted in Food and Drug Administration approval for anti-programmed death 1/programmed death ligand 1 ICIs, either in combination with anti-cytotoxic T-lymphocyte antigen 4 ICIs or with vascular endothelial growth factor-directed targeted therapies, as standard-of-care frontline regimens. Immune checkpoint inhibitors offer improved clinical outcomes when compared to previous treatment options. However, these agents also present unique toxicity profiles collectively referred to as immune-related adverse events. Common immune-related adverse events include colitis, hepatitis, dermatitis, and thyroiditis. Rare toxicities, such as myocarditis and pneumonitis, have the potential for causing severe harm. Herein, we provide a case-based discussion of how to identify, grade, and manage irAEs in metastatic renal cell carcinoma.
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144
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Pourvaziri A, Parakh A, Biondetti P, Sahani D, Kambadakone A. Abdominal CT manifestations of adverse events to immunotherapy: a primer for radiologists. Abdom Radiol (NY) 2020; 45:2624-2636. [PMID: 32451672 DOI: 10.1007/s00261-020-02531-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Immunotherapy is a rapidly growing field within oncology and is being increasingly used in the management of several malignancies. Due to their unique mechanism of action on the immune system and neoplastic cells, the response pattern and adverse events of this novel therapy are distinct from conventional systemic therapies. Accordingly, the imaging appearances following immunotherapy including adverse events are unique and at times perplexing. Imaging is integral to management of patients on immunotherapeutic agents and a thorough understanding of its mechanism, response patterns and adverse events is crucial for precise interpretation of imaging studies. This review provides a description of the mechanism of action of current immunotherapeutic agents and the organ-wise description of their side effects.
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Affiliation(s)
- Ali Pourvaziri
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Anushri Parakh
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Pierpaolo Biondetti
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Dushyant Sahani
- Department of Radiology, University of Washington, UWMC Radiology RR218, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Avinash Kambadakone
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA.
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145
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Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of immune-mediated cardiovascular, rheumatic, and renal toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6159-6173. [PMID: 32856212 DOI: 10.1007/s00520-020-05710-8] [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: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as the newest pillar of cancer treatment. Immune-mediated toxicities, stemming from increased activity within the T cell lineage, range from asymptomatic or mild complications to those that are fulminant and potentially fatal. Although they are of variable occurrence, cardiovascular, rheumatic, and renal immune-mediated toxicities are among the most serious of these adverse events. We present MASCC recommendations with respect to the workup and management of cardiovascular, rheumatic, and renal immune-mediated toxicities with a focus on presentations that require treatment with immunomodulating agents.
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146
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Williams SG, Mollaeian A, Katz JD, Gupta S. Immune checkpoint inhibitor-induced inflammatory arthritis: identification and management. Expert Rev Clin Immunol 2020; 16:771-785. [PMID: 32772596 DOI: 10.1080/1744666x.2020.1804362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have proved to be groundbreaking in the field of oncology. However, immune system overactivation from ICIs has introduced a novel medical entity known as immune-related adverse events (irAEs), that can affect any organ or tissue. ICI-induced inflammatory arthritis (ICI-IIA) is the most common musculoskeletal irAE and can lead to significant morbidity and limitation in anti-cancer therapy. AREAS COVERED In this review, the authors focus on ICI-IIA. Relevant articles were identified through PubMed searches, spanning 2010 to the present. The authors detail the current understanding of its pathogenesis, diagnostic evaluation, and management strategies. EXPERT OPINION ICI-IIA is a complex irAE that we are just beginning to understand mechanistically and pathologically. It often presents later in the disease course than other irAEs and, due to various reasons, is under-recognized. In some patients, ICI-IIA may become a chronic disease, which distinguishes it from most irAEs that resolve after ICI discontinuation. Multiple important questions still demand further research including which patients may develop ICI-IIA? What are possible diagnostic and prognostic markers? Do anti-arthritis therapies interfere with the anti-tumor response? and when should steroid-sparing agents be initiated? Close collaboration and shared decision-making between oncologists, rheumatologists, and the patient are essential when managing this particular irAE.
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Affiliation(s)
- Sandra G Williams
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
| | - Arash Mollaeian
- Department of Medicine, MedStar Health Internal Medicine Residency Program , Baltimore, MD, USA
| | - James D Katz
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
| | - Sarthak Gupta
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
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147
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Huang A, Yang XR, Chung WY, Dennison AR, Zhou J. Targeted therapy for hepatocellular carcinoma. Signal Transduct Target Ther 2020; 5:146. [PMID: 32782275 PMCID: PMC7419547 DOI: 10.1038/s41392-020-00264-x] [Citation(s) in RCA: 368] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/10/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023] Open
Abstract
The last 3 years have seen the emergence of promising targeted therapies for the treatment of hepatocellular carcinoma (HCC). Sorafenib has been the mainstay of treatment for a decade and newer modalities were ineffective and did not confer any increased therapeutic benefit until the introduction of lenvatinib which was approved based on its non-inferiority to sorafenib. The subsequent success of regorafenib in HCC patients who progress on sorafenib treatment heralded a new era of second-line treatment and was quickly followed by ramucirumab, cabozantinib, and the most influential, immune checkpoint inhibitors (ICIs). Over the same period combination therapies, including anti-angiogenesis agents with ICIs, dual ICIs and targeted agents in conjunction with surgery or other loco-regional therapies, have been extensively investigated and have shown promise and provided the basis for exciting clinical trials. Work continues to develop additional novel therapeutic agents which could potentially augment the presently available options and understand the underlying mechanisms responsible for drug resistance, with the goal of improving the survival of patients with HCC.
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Affiliation(s)
- Ao Huang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education, Shanghai, China.,Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin-Rong Yang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education, Shanghai, China.,Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Yuan Chung
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ashley R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jian Zhou
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China. .,Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education, Shanghai, China. .,Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China. .,Institute of Biomedical Sciences, Fudan University, Shanghai, China. .,State Key Laboratory of Genetic Engineering, Fudan University, Shanghai, China.
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148
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Gu Y, Zhang H, Liu Z, Xia Y, Liang B, Liang L. Different patterns of treatment-related adverse events of programmed cell death-1 and its ligand-1 inhibitors in different cancer types: A meta-analysis and systemic review of clinical trials. Asia Pac J Clin Oncol 2020; 16:e160-e178. [PMID: 32779383 DOI: 10.1111/ajco.13385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 05/13/2020] [Indexed: 12/17/2022]
Abstract
Programmed cell death receptor-1 and its ligand-1 (PD-1/PD-L1) inhibitors have been applied to many cancers, but the difference of treatment-related adverse events (AEs) across cancer types remains unknown. We performed a meta-analysis and systemic review to compare the incidences of commonly reported all-grade AEs across cancer types and found that the most frequent AEs were fatigue, rash/pruritus, loss of appetite/nausea and diarrhea. However, each cancer type also had its higher incidences of AEs involving a relevant system, such as melanoma with epidermal AEs (rash, diarrhea and enterocolitis), lung cancer with dyspnea and pneumonitis, digestive system cancers with amylase and lipase elevation; and renal cell and urothelial cancer with kidney injury (creatinine elevation and proteinuria). However, the incidence of hepatitis did not follow the pattern to show a difference. We did another comparison between PD-1 and PD-L1 inhibitors in lung cancer and urothelial cancer respectively, and found that the risk of most AEs did not differ much, except for more hypothyroidism in PD-1 inhibitors, and more kidney injury in PD-L1 inhibitors. Besides possible immunological mechanisms for treatment-related AEs, the influence of previous radiotherapy and the clinical characteristics of the diseases themselves should also be considered and is worth further investigation. With the result of this meta-analysis, clinicians could estimate the risk of certain AE in certain cancer type, to make treatment options and to customize monitor strategies.
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Affiliation(s)
- Yangchun Gu
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing, P.R. China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, P.R. China
| | - Zexiang Liu
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing, P.R. China
| | - Yifan Xia
- Institute of Medical Technology, Health Science Center, Peking University, Beijing, P.R. China
| | - Baosheng Liang
- Department of Biostatistics, School of Public Health, Peking University, Beijing, P.R. China
| | - Li Liang
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing, P.R. China
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149
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Diagnosis and Treatment of Rheumatic Adverse Events Related to Immune Checkpoint Inhibitors. J Immunol Res 2020; 2020:2640273. [PMID: 32832568 PMCID: PMC7424376 DOI: 10.1155/2020/2640273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/14/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have completely changed the treatment of cancer, and they also can cause multiple organ immune-related adverse reactions (irAEs). Among them, rheumatic irAE is less common, mainly including inflammatory arthritis, rheumatic myalgia/giant cell arteritis, inflammatory myopathy, and Sjogren's syndrome. For oncologists, rheumatism is a relatively new field, and early diagnosis and treatment is very important, and we need to work closely with experienced rheumatologists. In this review, we focused on the incidence, clinical characteristics, and treatment strategies of rheumatic irAE.
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150
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Roberts J, Ennis D, Hudson M, Ye C, Saltman A, Himmel M, Rottapel R, Pope J, Hoa S, Tisseverasinghe A, Fifi-Mah A, Maltez N, Jamal S. Rheumatic immune-related adverse events associated with cancer immunotherapy: A nationwide multi-center cohort. Autoimmun Rev 2020; 19:102595. [DOI: 10.1016/j.autrev.2020.102595] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022]
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