101
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Jennings JJ, Mandaliya R, Nakshabandi A, Lewis JH. Hepatotoxicity induced by immune checkpoint inhibitors: a comprehensive review including current and alternative management strategies. Expert Opin Drug Metab Toxicol 2019; 15:231-244. [PMID: 30677306 DOI: 10.1080/17425255.2019.1574744] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) block cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1)/PD ligand 1 (PD-L1) receptors that control antitumor activities of lymphocytes. While highly efficacious, these drugs have been associated with several immune-related adverse events (irAEs) due to the disruption of self-tolerance. Immune-mediated hepatitis (IMH) usually presents as mild elevations of liver enzymes though it can rarely be associated with life-threatening hepatic injury. Areas covered: A comprehensive review was performed to define the clinicopathologic forms of liver injury associated with ICIs, comparing the various ICI classes as well as comparing this form of IMH with idiopathic autoimmune hepatitis and drug-induced autoimmune hepatitis. Liver biopsy has proven very useful in selected patients. A specific form of fibrin ring granulomatous hepatitis appears to be associated with IMH. The current societal treatment algorithms and emerging data were reviewed to determine when to utilize corticosteroids. Expert opinion: Monitoring for severe ICI-IMH is recommended although acute liver failure remains rare. Most patients with grade 3-4 hepatotoxicity respond to corticosteroids, but a subset of patients with mild hepatitis on liver biopsy resolve without steroids and need to be carefully selected in concert with the consultation of a hepatologist.
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Affiliation(s)
- Joseph J Jennings
- a Department of Medicine, Division of Gastroenterology and Hepatology , MedStar Georgetown University Hospital , Washington , DC , USA
| | - Rohan Mandaliya
- a Department of Medicine, Division of Gastroenterology and Hepatology , MedStar Georgetown University Hospital , Washington , DC , USA
| | - Ahmad Nakshabandi
- b Department of Internal Medicine , Mercy Hospital and Medical Center , Chicago , IL , USA
| | - James H Lewis
- a Department of Medicine, Division of Gastroenterology and Hepatology , MedStar Georgetown University Hospital , Washington , DC , USA
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102
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Lemiale V, Meert AP, Vincent F, Darmon M, Bauer PR, Van de Louw A, Azoulay E. Severe toxicity from checkpoint protein inhibitors: What intensive care physicians need to know? Ann Intensive Care 2019; 9:25. [PMID: 30707321 PMCID: PMC6358632 DOI: 10.1186/s13613-019-0487-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 01/12/2019] [Indexed: 12/13/2022] Open
Abstract
Checkpoint protein inhibitor antibodies (CPI), including cytotoxic T-lymphocyte-associated antigen 4 inhibitors (ipilimumab, tremelimumab) and the programmed cell death protein 1 pathway/programmed cell death protein 1 ligand inhibitors (pembrolizumab, nivolumab, durvalumab, atezolizumab), have entered routine practice for the treatment of many cancers. They improve the outcome for many cancers, and more patients will be treated with CPI in the future. Although CPI can lead to adverse events (AE) less frequently than for chemotherapy, their use can require intensive care unit admission in case of severe immune-related adverse events (IrAE). Moreover, some of these events, particularly late events, are poorly documented, so a high level of suspicion should be maintained for patients receiving CPI. Intensivists should be aware in general of the known complications and appropriate management of these AE. Nevertheless, a multidisciplinary collaboration remains essential for their diagnosis and management. This review described the most severe complications related to CPI.
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Affiliation(s)
- Virginie Lemiale
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Paris, France.
| | - Anne-Pascale Meert
- Soins Intensifs et urgences oncologiques, Institut Jules Bordet (ULB), Brussels, Belgium
| | - François Vincent
- Medical Surgical ICU, GHIC Le Raincy-Montfermeil, 93370, Montfermeil, France
| | - Michael Darmon
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Paris, France.,ECSTRA, Saint Louis SBIM, APHP, Paris, France
| | | | - Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Penn State University College of Medicine, Hershey, PA, USA
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Paris, France.,ECSTRA, Saint Louis SBIM, APHP, Paris, France
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103
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Hodgson A, Almansouri Z, Adeyi O, Fischer SE. Gross and microscopic changes of liver neoplasms and background hepatic structures following neoadjuvant therapy. J Clin Pathol 2019; 72:112-119. [PMID: 30670563 DOI: 10.1136/jclinpath-2018-205596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 01/03/2023]
Abstract
Liver transplantation is a surgical option with curative intent used in the management of some cases of hepatocellular carcinoma and cholangiocarcinoma (hilar, rarely intrahepatic). A number of different therapeutic modalities including ablative techniques, arterially directed therapies, radiation and chemotherapy are used in the neoadjuvant setting prior to liver transplantation with the goals of preventing tumour progression, decreasing post-transplant recurrence and possibly downstaging patients with tumour burden beyond what is acceptable by current transplant criteria. Pathologists evaluating hepatic explants must be aware of these neoadjuvant therapies and the alterations induced by them in both tumourous and non-tumourous tissue. In this review, we discuss common neoadjuvant therapies used in in this setting, as well as the gross and microscopic changes induced by these presurgical treatments within hepatic neoplasms as well as the background hepatic parenchyma and nearby structures. Select secondary tumours involving the liver which are pretreated will also be discussed. Finally, proper reporting of these changes will be mentioned.
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Affiliation(s)
- Anjelica Hodgson
- Department of Pathobiology and Laboratory Medicine, The University of Toronto, Toronto, Ontario, Canada.,Department of Pathology, University Health Network, Toronto, Ontario, Canada
| | - Zuhoor Almansouri
- Department of Pathobiology and Laboratory Medicine, The University of Toronto, Toronto, Ontario, Canada.,Department of Pathology, University Health Network, Toronto, Ontario, Canada
| | - Oyedele Adeyi
- Department of Pathobiology and Laboratory Medicine, The University of Toronto, Toronto, Ontario, Canada.,Department of Pathology, University Health Network, Toronto, Ontario, Canada
| | - Sandra E Fischer
- Department of Pathobiology and Laboratory Medicine, The University of Toronto, Toronto, Ontario, Canada .,Department of Pathology, University Health Network, Toronto, Ontario, Canada
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104
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Baroudjian B, Arangalage D, Cuzzubbo S, Hervier B, Lebbé C, Lorillon G, Tazi A, Zalcman G, Bouattour M, Lioté F, Gautier JF, Brosseau S, Lourenco N, Delyon J. Management of immune-related adverse events resulting from immune checkpoint blockade. Expert Rev Anticancer Ther 2019; 19:209-222. [PMID: 30572735 DOI: 10.1080/14737140.2019.1562342] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICI) are now a standard of care in the treatment of many cancers leading to durable responses in patients with metastatic disease. These agents are generally well tolerated but may lead to the occurrence of immune-related adverse events (irAEs). As any organ may be affected, clinicians should be aware of the broad range of clinical manifestations and symptoms and keep in mind that toxicities may occur late, at any point along a patient's treatment course. Although the most common irAEs are rarely severe, some of them may be associated with great morbidity and even become life-threatening. The rate of occurrence, type and severity of irAEs may vary with the type of ICI; thus, grade 3 and 4 irAEs are reported in more than 55% of patients treated with the combination of ipilimumab 3 mg/kg and nivolumab 1 mg/kg. Area covered: This review presents the management of irAEs resulting from checkpoint blockade, with a focus on rare irAEs. Expert commentary: With the development of immuno-oncology and the expanding role of ICI, physicians have learnt to diagnose and treat most of the irAEs that can occur. This review provides an overview of current guidelines, previously published studies and our multidisciplinary team based practices.
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Affiliation(s)
| | - Dimitri Arangalage
- b Université Paris 7 Diderot, Sorbonne , Paris , France.,c Department of Cardiology, INSERM U1148 , Bichat Hospital , Paris , France
| | - Stefania Cuzzubbo
- b Université Paris 7 Diderot, Sorbonne , Paris , France.,d Neurology Department , Saint-Louis Hospital , Paris , France
| | - Baptiste Hervier
- e Internal Medecine and immunology Department , Centre National de Référence des Maladies Musculaires, Pitié-Salpêtrière Hospital , Paris , France
| | - Celeste Lebbé
- a Dermatology Department , Saint-Louis Hospital , Paris , France.,b Université Paris 7 Diderot, Sorbonne , Paris , France.,f INSERM U976 , Paris , France
| | - Gwenael Lorillon
- g Pneumology Department , Centre National de Référence de l'Histiocytose Langerhansienne, Saint-Louis Hospital , Paris , France
| | - Abdellatif Tazi
- b Université Paris 7 Diderot, Sorbonne , Paris , France.,h INSERM UMR-1153 (CRESS) , Biostatistics and Clinical Epidemiology Research Team (ECSTRA) , Paris , France
| | - Gerard Zalcman
- b Université Paris 7 Diderot, Sorbonne , Paris , France.,i Thoracic Oncology Department , Bichat-Claude Bernard Hospital , Paris , France
| | - Mohamed Bouattour
- j Digestive Oncology Department , Beaujon Hospital , Clichy , France
| | - Frédéric Lioté
- b Université Paris 7 Diderot, Sorbonne , Paris , France.,k Rheumatology Department, INSERM UMR 1132 , Lariboisière Hospital , Paris , France
| | - Jean-François Gautier
- b Université Paris 7 Diderot, Sorbonne , Paris , France.,l Endocrinology Department , Lariboisière Hospital , Paris , France
| | - Solenn Brosseau
- i Thoracic Oncology Department , Bichat-Claude Bernard Hospital , Paris , France
| | - Nelson Lourenco
- m Gastro-enterology Department , Saint-Louis Hospital , Paris , France
| | - Julie Delyon
- a Dermatology Department , Saint-Louis Hospital , Paris , France.,b Université Paris 7 Diderot, Sorbonne , Paris , France.,f INSERM U976 , Paris , France
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105
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Nishino M, Hatabu H, Hodi FS. Imaging of Cancer Immunotherapy: Current Approaches and Future Directions. Radiology 2019; 290:9-22. [PMID: 30457485 PMCID: PMC6312436 DOI: 10.1148/radiol.2018181349] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 12/20/2022]
Abstract
Cancer immunotherapy using immune-checkpoint inhibitors has emerged as an effective treatment option for a variety of advanced cancers in the past decade. Because of the distinct mechanisms of immunotherapy that activate the host immunity to treat cancers, unconventional immune-related phenomena are encountered in terms of tumor response and progression, as well as drug toxicity. Imaging plays an important role in objectively characterizing immune-related tumor responses and progression and in detecting and monitoring immune-related adverse events. Moreover, emerging data suggest a promise for molecular imaging that can visualize the specific target molecules involved in immune-checkpoint pathways. In this article, the background and current status of cancer immunotherapy are summarized, and the current methods for imaging evaluations of immune-related responses and toxicities are reviewed along with their limitations and pitfalls. Emerging approaches with molecular imaging are also discussed as a future direction to address unmet needs.
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Affiliation(s)
- Mizuki Nishino
- From the Departments of Radiology (M.N., H.H.), Medical Oncology (F.S.H.), and Medicine (F.S.H.), Brigham and Women’s Hospital and Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215
| | - Hiroto Hatabu
- From the Departments of Radiology (M.N., H.H.), Medical Oncology (F.S.H.), and Medicine (F.S.H.), Brigham and Women’s Hospital and Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215
| | - F. Stephen Hodi
- From the Departments of Radiology (M.N., H.H.), Medical Oncology (F.S.H.), and Medicine (F.S.H.), Brigham and Women’s Hospital and Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215
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106
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Tang YZ, Szabados B, Leung C, Sahdev A. Adverse effects and radiological manifestations of new immunotherapy agents. Br J Radiol 2019; 92:20180164. [PMID: 30281331 PMCID: PMC6435070 DOI: 10.1259/bjr.20180164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 01/08/2023] Open
Abstract
Immunotherapy has had increasing use in Medical Oncology for a diverse range of primary malignancies. There are various types of immunotherapy which are grouped based on mechanism of action. In recent decades, the immune checkpoint inhibitors (ICI) immunotherapies have been at the forefront of Medical Oncology, sparked by very encouraging results. Some patients with metastatic cancer who were previously deemed palliative were seeing durable response rates and significant increased survival with ICIs. The mechanism of action of ICIs vary wildly compared to the conventional, cytotoxic chemotherapy, upon which traditional radiology response criteria were based and validated upon. Novel responses such as pseudo progression, disease response in the context of new metastases and prolonged stable disease were observed and correlated with improved patient survival with ICI. New radiology response criteria were proposed to better capture disease response to ICI; however, the criteria have been applied heterogeneously and there is continued work in this sector. In addition to the novel responses, ICIs have been linked to numerous, diverse immune-related adverse events (irAE) affecting multiple systems. A large majority of these are mild, but some irAEs are life threatening. Only some of the irAEs have radiological manifestations. It is important that the reporting radiologist recognises potential irAE so clinical teams can be alerted, ICI treatment paused or cessated and steroid treatment initiated. This review will discuss the evolution of the radiology response criteria in ICI and the varied radiological appearances of irAE.
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Affiliation(s)
- Yen Zhi Tang
- St Bartholomew’s Hospital West Smithfields London , London, UK
| | | | - Cindy Leung
- St Bartholomew’s Hospital West Smithfields London , London, UK
| | - Anju Sahdev
- St Bartholomew’s Hospital West Smithfields London , London, UK
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107
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Ahmed M. Checkpoint inhibitors: What gastroenterologists need to know. World J Gastroenterol 2018; 24:5433-5438. [PMID: 30622372 PMCID: PMC6319137 DOI: 10.3748/wjg.v24.i48.5433] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/07/2018] [Accepted: 11/16/2018] [Indexed: 02/06/2023] Open
Abstract
Checkpoint inhibitors are increasingly being used in clinical practice. They can cause various gastrointestinal, hepatic and pancreatic side effects. As these side effects can be serious, appropriate management is essential. The different checkpoint inhibitors with their mechanisms of action and indications, as well as evaluation and management of gastrointestinal, hepatic and pancreatic side effects, are discussed in this article.
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Affiliation(s)
- Monjur Ahmed
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States
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108
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Wirsdörfer F, de Leve S, Jendrossek V. Combining Radiotherapy and Immunotherapy in Lung Cancer: Can We Expect Limitations Due to Altered Normal Tissue Toxicity? Int J Mol Sci 2018; 20:ijms20010024. [PMID: 30577587 PMCID: PMC6337556 DOI: 10.3390/ijms20010024] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 02/08/2023] Open
Abstract
In recent decades, technical advances in surgery and radiotherapy, as well as breakthroughs in the knowledge on cancer biology, have helped to substantially improve the standard of cancer care with respect to overall response rates, progression-free survival, and the quality of life of cancer patients. In this context, immunotherapy is thought to have revolutionized the standard of care for cancer patients in the long term. For example, immunotherapy approaches such as immune checkpoint blockade are currently increasingly being used in cancer treatment, either alone or in combination with chemotherapy or radiotherapy, and there is hope from the first clinical trials that the appropriate integration of immunotherapy into standard care will raise the success rates of cancer therapy to a new level. Nevertheless, successful cancer therapy remains a major challenge, particularly in tumors with either pronounced resistance to chemotherapy and radiation treatment, a high risk of normal tissue complications, or both, as in lung cancer. Chemotherapy, radiotherapy and immunotherapy have the capacity to evoke adverse effects in normal tissues when administered alone. However, therapy concepts are usually highly complex, and it is still not clear if combining immunotherapy with radio(chemo)therapy will increase the risk of normal tissue complications, in particular since normal tissue toxicity induced by chemotherapy and radiotherapy can involve immunologic processes. Unfortunately, no reliable biomarkers are available so far that are suited to predict the unique normal tissue sensitivity of a given patient to a given treatment. Consequently, clinical trials combining radiotherapy and immunotherapy are attracting major attention, not only regarding efficacy, but also with regard to safety. In the present review, we summarize the current knowledge of radiation-induced and immunotherapy-induced effects in tumor and normal tissue of the lung, and discuss the potential limitations of combined radio-immunotherapy in lung cancer with a focus on the suspected risk for enhanced acute and chronic normal tissue toxicity.
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Affiliation(s)
- Florian Wirsdörfer
- Institute of Cell Biology (Cancer Research), University Hospital Essen, 45147 Essen, Germany.
| | - Simone de Leve
- Institute of Cell Biology (Cancer Research), University Hospital Essen, 45147 Essen, Germany.
| | - Verena Jendrossek
- Institute of Cell Biology (Cancer Research), University Hospital Essen, 45147 Essen, Germany.
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109
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Kwan JM, Cheng R, Feldman LE. Hepatotoxicity and Recurrent NSTEMI While on Pembrolizumab for Metastatic Giant Cell Bone Tumor. Am J Med Sci 2018; 357:343-347. [PMID: 30638772 DOI: 10.1016/j.amjms.2018.11.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 11/17/2018] [Accepted: 11/26/2018] [Indexed: 12/22/2022]
Abstract
We present the first reported case showing metastatic giant bone cell tumor being treated successfully with pembrolizumab after failing prior tyrosine kinase inhibitor therapy. Of note, the patient developed multiple systemic effects associated with checkpoint inhibitor use. One year after starting the checkpoint inhibitor (ICI), the patient also developed hepatitis that was confirmed by liver biopsy and pathology to be, in part, due to drug-mediated toxicity similar to prior ICI toxicity cases that have been reported. Additionally, although the patient had vascular risk factors (hypertension, diabetes and smoking), it was notable from a cardiology perspective that the patient developed 2 subsequent non-ST-elevation myocardial infarctions, with rapid progression of stenosis of the left circumflex artery 2 months apart. The first left heart catheterization showing minimal disease of the left circumflex, but 2 months later, presenting with chest pain, a repeat left heart catheterization showed significant stenosis of the left proximal circumflex, raising the possibilities that either ICI can promote plaque rupture and/or accelerated atherosclerosis; both phenomena have been shown to occur in animal models. The patient also developed thyroiditis with subsequent hypothyroidism, now on thyroid replacement from checkpoint inhibitor use. This case demonstrates the multiorgan adverse effects this new antioncologic agent can have and yet also its promising antitumor effects. Awareness of the side effects among primary care doctors and all specialists will be helpful in managing these potential side effects and research will help elucidate ways to prevent the adverse effects.
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Affiliation(s)
- Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
| | - Renee Cheng
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Lawrence E Feldman
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois; Division of Hematology/Oncology, University of Illinois Chicago, Chicago, Illinois
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110
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Grover S, Rahma OE, Hashemi N, Lim RM. Gastrointestinal and Hepatic Toxicities of Checkpoint Inhibitors: Algorithms for Management. Am Soc Clin Oncol Educ Book 2018; 38:13-19. [PMID: 30231401 DOI: 10.1200/edbk_100013] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastrointestinal toxicities are among the leading causes of immune-related adverse effects of checkpoint blockade. These adverse events can be severe enough to require interruption or withdrawal of immune checkpoint blockade therapy. Patients with immune-related adverse effects require early recognition with an evaluation to rule out alternative etiologies and effective management to minimize complications. This article reviews the gastrointestinal and hepatic toxicities of the antibodies that target immune checkpoints CTLA-4 and PD-1/PD-L1 and provides an approach to their diagnosis and management.
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Affiliation(s)
- Shilpa Grover
- From the Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Brookline, MA
| | - Osama E Rahma
- From the Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Brookline, MA
| | - Nikroo Hashemi
- From the Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Brookline, MA
| | - Ramona M Lim
- From the Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Brookline, MA
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111
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Belli C, Zuin M, Mazzarella L, Trapani D, D'Amico P, Guerini-Rocco E, Achutti Duso B, Curigliano G. Liver toxicity in the era of immune checkpoint inhibitors: A practical approach. Crit Rev Oncol Hematol 2018; 132:125-129. [PMID: 30447917 DOI: 10.1016/j.critrevonc.2018.09.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/10/2018] [Accepted: 09/29/2018] [Indexed: 12/28/2022] Open
Abstract
Immune checkpoint inhibitors have revolutionized the cancer treatment with an approved efficacy in different solid tumors and hematologic malignancies. These agents are increasing the indication in cancer treatment, but can be associated with serious immune-related adverse effects (IRAEs). Dermatologic and gastrointestinal toxicities are the most common IRAE followed by endocrinopathies with a different time of occurrence. Rarely cases of gastrointestinal toxicities are observed almost 2 years after initiation of the therapy. In this review we focus on liver toxicity related to these immunotherapeutic agents for which the largest amount of safety data is available. The management of drug-induced liver toxicity is very complicated and in same cases may take a long period of time to be resolved. A prompt recognition of liver IRAEs and an appropriate management of this event, requiring close collaboration with other specialist figures, could improve its treatment with evident implication on the efficacy of the therapy.
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Affiliation(s)
- Carmen Belli
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy.
| | - Massimo Zuin
- Division of Internal Medicine and Liver Unit, Department of Medicine San Paolo Hospital School of Medicine, University of Milan, via di Rudiní 8, 20142, Milan, Italy
| | - Luca Mazzarella
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
| | - Dario Trapani
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
| | - Paolo D'Amico
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
| | - Elena Guerini-Rocco
- Division of Pathology, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Bruno Achutti Duso
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, via Festa del Perdono 7, 20122 Milan, Italy
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112
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Immune Checkpoint Inhibitor-Associated Colitis and Hepatitis. Clin Transl Gastroenterol 2018; 9:180. [PMID: 30228268 PMCID: PMC6143593 DOI: 10.1038/s41424-018-0049-9] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/02/2018] [Accepted: 08/04/2018] [Indexed: 01/03/2023] Open
Abstract
Immune checkpoint inhibitors (ICPIs) are monoclonal antibodies that target downregulators of the anti-cancer immune response: cytotoxic T-lymphocyte antigen-4, programmed cell death protein-1, and its ligand PD-L1. ICPIs are now approved for the treatment of a wide array of malignancies, with rates of durable responses in the metastatic setting far exceeding what would be expected from conventional chemotherapy. ICPIs have also been associated with rare but serious immune-related adverse events due to over-activation of the immune system that can affect any organ, including the gastrointestinal tract and liver. As the use of ICPIs in oncology continues to increase, ICPI-associated colitis and hepatitis will be encountered frequently by gastroenterologists and hepatologists. This review will focus on the diagnosis and management of ICPI-associated colitis and hepatitis. We will also compare these ICPI-related toxicities with sporadic inflammatory bowel disease and autoimmune liver disease.
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113
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Reynolds K, Thomas M, Dougan M. Diagnosis and Management of Hepatitis in Patients on Checkpoint Blockade. Oncologist 2018; 23:991-997. [PMID: 29853659 PMCID: PMC6192661 DOI: 10.1634/theoncologist.2018-0174] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/08/2018] [Indexed: 12/26/2022] Open
Abstract
Many human tumors are recognized by the adaptive immune system, but these spontaneous antitumor responses are typically inadequate to mediate regression. Blockade of immune regulatory "checkpoint" receptors such as cytotoxic T-lymphocyte-associated antigen 4 and programmed cell death 1 can unleash antitumor immunity, resulting in tumor responses that can be durable. Alongside the enormous promise of immunotherapy for cancer, the immune dysregulation of checkpoint blockade has led to a plethora of new autoimmune adverse events. Hepatic toxicity occurs in 1%-17% of patients on immune checkpoint inhibitors, with the precise incidence dependent on both the drug used and the underlying malignancy. Hepatitis is most commonly a low-grade toxicity, but grade 3 and 4 hepatotoxicity does occur. Here we will answer frequently asked questions regarding immune-related hepatitis to assist in the recognition and management of this important condition. KEY POINTS Immune related hepatitis is a potentially serious complication of checkpoint blockade.The differential for elevated liver function tests in patients on checkpoint blockade is broad.Diagnostic testing such as viral serologies, liver ultrasound, cross sectional imaging, and liver biopsy may help in the diagnosis of immune related hepatitis in select patients.Patients with underlying cirrhosis are an at risk population for whom current grading criteria may underestimate the severity of liver inflammation.Severe immune related hepatitis is best managed by a multi-disciplinary team that includes a hepatologist.Most patients with immune related hepatitis respond to corticosteroids, but a substantial fraction require treatment with a secondary immunosuppressive agent.
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Affiliation(s)
- Kerry Reynolds
- Division of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Molly Thomas
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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114
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Hansen ED, Wang X, Case AA, Puzanov I, Smith T. Immune Checkpoint Inhibitor Toxicity Review for the Palliative Care Clinician. J Pain Symptom Manage 2018; 56:460-472. [PMID: 29792979 DOI: 10.1016/j.jpainsymman.2018.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/15/2018] [Accepted: 05/15/2018] [Indexed: 12/22/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have opened an exciting chapter in the treatment of patients with advanced cancer. For the palliative care clinician, however, ICIs present several new challenges, including new ways to define treatment success, as well as treatment-related toxicities that differ in nature and timing from traditional chemotherapy. In this article, we review the mechanism of action of ICIs, as well as selected published data supporting the efficacy of ICIs in patients with advanced cancer. In addition, we summarize existing data of ICI toxicity prevalence, patterns of severity, and timing of onset. Finally, we briefly review key principles from published guidelines on the management of ICI toxicities.
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Affiliation(s)
- Eric D Hansen
- Department of Supportive Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.
| | - Xiao Wang
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Amy A Case
- Department of Supportive Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Igor Puzanov
- Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Tom Smith
- Palliative Medicine Program, Johns Hopkins Hospital, Baltimore, Maryland, USA
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115
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[Hepatic and digestive adverse events of immune checkpoint inhibitors (anti-CTLA-4 and, anti-PD-1/PD-L1): A clinico-pathological review]. Ann Pathol 2018; 38:338-351. [PMID: 30143243 DOI: 10.1016/j.annpat.2018.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/23/2018] [Accepted: 07/13/2018] [Indexed: 12/20/2022]
Abstract
Immune checkpoint inhibitors (anti-CTLA-4 and anti-PD-1/PD-L1) have recently revolutionized anti-cancer therapy and are nowadays used in different metastatic cancers. These treatments may induce immune-related adverse events which frequently involve the digestive tract and, to a less extent the liver. The tissular injuries, which are still poorly characterized from a morphological and physiopathological point of view, may lead on one side to the interruption of a life-saving treatment and on the other side to the development of severe complications, if not death. Therefore, it is crucial to diagnose as early as possible and treat these digestive and hepatic adverse effects in an optimal way. This article aims to describe the clinical and pathological presentations of digestive and hepatic adverse events induced by these immunotherapies.
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116
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Wills B, Brahmer JR, Naidoo J. Treatment of Complications from Immune Checkpoint Inhibition in Patients with Lung Cancer. Curr Treat Options Oncol 2018; 19:46. [PMID: 30101402 PMCID: PMC7102206 DOI: 10.1007/s11864-018-0562-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OPINION STATEMENT Immune checkpoint inhibitors have revolutionized the management of advanced NSCLC. With the intention of generating an anti-tumor immune response, ICIs can also lead to inflammatory side effects involving a wide variety of organs in the body, termed immune-related adverse events. Although no prospective clinical trial exists to guide recommendations for optimal and more specific immunosuppressive treatments rather than corticosteroids, further studies may lead to a more mechanistic-based approach towards these toxicities in the future. In relation to current practice, we recommend adherence to the recent published guidelines which emphasize the importance of early recognition and administration of temporary immunosuppressive therapy with corticosteroids in most cases, depending on the organ system involved, and the severity of toxicity. Recognition of these toxicities is increasingly important as the use of these agents expand within different indications for patients with lung cancers, and to other tumor types.
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Affiliation(s)
- Beatriz Wills
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Bayview, Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Julie R. Brahmer
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Bayview, Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD 21224 USA
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, MD USA
| | - Jarushka Naidoo
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Bayview, Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD 21224 USA
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, MD USA
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Abstract
OBJECTIVE The hallmarks of cancer are mechanisms that cells develop to undergo malignant transformation. The targeting of these hallmarks by newer cancer therapies results in new mechanisms of response, toxicity, and resistance. The purpose of this article is to review these hallmarks, their associated targeted therapies, imaging features of responses, and toxicities. CONCLUSION Ten hallmarks, among them proliferative signaling, angiogenesis, immune response, and genome instability, are reviewed. Molecular targeted therapies, including antiangiogenic factors and immune checkpoint inhibitors, target these hallmarks.
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118
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Chascsa DM, Rakela J. Knowns and Unknowns: the Safety and Efficacy of Cancer Immunotherapy in Chronic Liver Disease. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s11901-018-0408-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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119
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Abstract
The latest cancer agents, collectively known as cancer immunotherapy, have tremendously increased the armamentarium against cancer. Their targeted mechanisms seem ideal, but they do come with complications. As these therapies become more widespread, emergency physicians everywhere must be aware of the immune-related adverse events that can occur, and be ready to identify and coordinate treatment. This article provides the emergency physician with a brief introduction and overview of immunotherapy drugs and their complications.
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Affiliation(s)
- Sarah B Dubbs
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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120
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Hepatotoxicity of immune checkpoint inhibitors: a histology study of seven cases in comparison with autoimmune hepatitis and idiosyncratic drug-induced liver injury. Mod Pathol 2018; 31:965-973. [PMID: 29403081 DOI: 10.1038/s41379-018-0013-y] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/12/2017] [Accepted: 12/03/2017] [Indexed: 12/13/2022]
Abstract
The adverse effects of immune checkpoint inhibitors in various organs may be attributed to immune-mediated processes triggered by disrupted self-tolerance; however, it remains unclear whether they are similar or dissimilar to classic organ-specific autoimmune diseases. The present study aimed to compare clinicopathologic features between checkpoint inhibitor-induced liver injury and acutely presenting autoimmune hepatitis or idiosyncratic drug-induced liver injury. Seven patients treated with nivolumab (n = 5) or ipilimumab (n = 2) presented with liver dysfunction a median of 41 days (range 21-120) after the initiation of immunotherapy. All patients had elevated liver enzymes, whereas hyper-bilirubinemia was less common. None of the patients had antinuclear antibodies or IgG elevations. Stopping the immunotherapy and additional immunosuppression with corticosteroids normalized or decreased liver enzymes in all patients treated. Histologically, all biopsies showed predominantly lobular hepatitis with milder portal inflammation. Centrilobular confluent necrosis and plasmacytosis were observed in a single case, and were markedly less common and milder than those in autoimmune hepatitis (p = 0.017 and p < 0.001, respectively). Bile duct injury, micro-abscesses, and extramedullary hematopoiesis were also found in one case each. Immunostaining revealed the presence of large numbers of CD3+ and CD8+ lymphocytes, whereas CD20+ B cells and CD4+ T cells were fewer in checkpoint inhibitor-induced liver injury than in autoimmune hepatitis or drug-induced liver injury. In conclusion, liver injury caused by cancer immunotherapy shares some features with injury of autoimmune hepatitis; however, there are obvious differences between the two conditions. Checkpoint inhibitor-induced liver injury may represent an immune-mediated, less zone-selective hepatocyte necrosis not requiring the strong activation of helper T cells and immunoglobulin production.
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121
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Suzman DL, Pelosof L, Rosenberg A, Avigan MI. Hepatotoxicity of immune checkpoint inhibitors: An evolving picture of risk associated with a vital class of immunotherapy agents. Liver Int 2018; 38:976-987. [PMID: 29603856 DOI: 10.1111/liv.13746] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/21/2018] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors (ICIs) block CTLA-4, PD-1 and PD-L1, or other molecules that control antitumour activities of lymphocytes. These products are associated with a broad array of immune-related toxicities affecting a variety of organs, including the liver. ICI-associated immune-mediated hepatitis (IMH) ranges in severity between mild and life-threatening and is marked by findings that bear both similarities as well as differences with idiopathic autoimmune hepatitis. Hepatotoxic events are often detected in clinical trials of ICIs that are powered for efficacy. Risk levels for ICI-induced liver injury may be impacted by the specific checkpoint molecule targeted for treatment, the ICI dose levels, and the presence of a pre-existing autoimmune diathesis, chronic infection or tumour cells which infiltrate the liver parenchyma. When patients develop liver injury during ICI treatment, a prompt assessment of the cause of injury, in conjunction with the application of measures to optimally manage the adverse event, should be made. Strategies to manage the risk of IMH include the performance of pretreatment liver tests with regular monitoring during and after ICI treatment and patient education. Using Common Terminology Criteria for Adverse Events developed at the National Cancer Institute to measure the severity level of liver injury, recommended actions may include continued ICI treatment with close patient monitoring, ICI treatment suspension or discontinuation and/or administration of corticosteroids or, when necessary, a non-steroidal immunosuppressive agent. The elucidation of reliable predictors of tumour-specific ICI treatment responses, as well as an increased susceptibility for clinically serious immune-related adverse events, would help optimize treatment decisions for individual patients.
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Affiliation(s)
- Daniel L Suzman
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Lorraine Pelosof
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Amy Rosenberg
- Office of Biotechnology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Mark I Avigan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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122
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Immunotherapy in Non-Small Cell Lung Cancer Treatment: Current Status and the Role of Imaging. J Thorac Imaging 2018; 32:300-312. [PMID: 28786858 DOI: 10.1097/rti.0000000000000291] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Lung cancer remains the leading cause of cancer-related mortality and is responsible for more deaths than breast, prostate, and colon cancer combined. Most patients are diagnosed with advanced disease at the time of presentation, and treatment options have traditionally included surgery, chemotherapy, and/or radiation. However, significant advances in the molecular characterization of lung cancer have led to the creation of effective immunotherapies that assist in the recognition of cancer as foreign by the host immune system, stimulate the immune system, and relieve the inhibition that allows tumor growth and spread. Extensive experience with the immunomodulatory monoclonal antibody ipilimumab has demonstrated that unique responses may be seen with immunotherapies that are not adequately captured by traditional response criteria such as the World Health Organization criteria and Response Evaluation Criteria in Solid Tumors (RECIST). Consequently, several modified criteria have been developed to evaluate patients treated with immunotherapy, including immune-related response criteria, immune-related RECIST, and immune RECIST. Finally, patients undergoing immunotherapy may develop a wide variety of immune-related adverse events with which the radiologist must be familiar. In this article, we present the fundamental concepts behind immunotherapy, specific agents currently approved for the treatment of lung cancer, and immune-related adverse events. The role of imaging in the evaluation of these patients will also be discussed, including the general principles of treatment response evaluation, specific response criteria adopted with these agents, including immune-related response criteria, immune-related RECIST, and immune RECIST, and the imaging of immune-related adverse events.
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123
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Karamchandani DM, Chetty R. Immune checkpoint inhibitor-induced gastrointestinal and hepatic injury: pathologists' perspective. J Clin Pathol 2018; 71:665-671. [PMID: 29703758 DOI: 10.1136/jclinpath-2018-205143] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 12/15/2022]
Abstract
Immune checkpoint inhibitors (CPIs) are a relatively new class of 'miracle' dugs that have revolutionised the treatment and prognosis of some advanced-stage malignancies, and have increased the survival rates significantly. This class of drugs includes cytotoxic T lymphocyte antigen-4 inhibitors such as ipilimumab; programmed cell death protein-1 inhibitors such as nivolumab, pembrolizumab and avelumab; and programmed cell death protein ligand-1 inhibitors such as atezolizumab. These drugs stimulate the immune system by blocking the coinhibitory receptors on the T cells and lead to antitumoural response. However, a flip side of these novel drugs is immune-related adverse events (irAEs), secondary to immune-mediated process due to disrupted self-tolerance. The irAEs in the gastrointestinal (GI) tract/liver may result in diarrhoea, colitis or hepatitis. An accurate diagnosis of CPI-induced colitis and/or hepatitis is essential for optimal patient management. As we anticipate greater use of these drugs in the future given the significant clinical response, pathologists need to be aware of the spectrum of histological findings that may be encountered in GI and/or liver biopsies received from these patients, as well as differentiate them from its histopathological mimics. This present review discusses the clinical features, detailed histopathological features, management and the differential diagnosis of the luminal GI and hepatic irAEs that may be encountered secondary to CPI therapy.
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Affiliation(s)
- Dipti M Karamchandani
- Division of Anatomic Pathology, Department of Pathology, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Runjan Chetty
- Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
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124
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Late-onset nivolumab-mediated pneumonitis in a patient with melanoma and multiple immune-related adverse events. Melanoma Res 2018; 27:391-395. [PMID: 28419059 DOI: 10.1097/cmr.0000000000000355] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Immune-related adverse effects (AEs) of PD-1 inhibitors can affect almost every organ, but the skin, intestine, lung, eye, and liver are the most commonly affected organs. Here, we present the case of a 62-year-old female patient with stage IIIc melanoma treated with nivolumab in an adjuvant setting who sequentially developed hyperthyroidism, hypothyroidism, acute hepatitis, and pneumonitis. Six months before the emergence of pneumonitis, the patient had discontinued treatment with nivolumab because of acute hepatitis. Information on pneumonitis after nivolumab discontinuation in the literature is scarce, whereas most of the cases emerge during the first 2.5 months of treatment. Patients with multiple immune-related AEs comprise a group of special interest as the identification of factors affecting the susceptibility of patients to immune-related AEs of PD-1 inhibitors may lead to a more rational use of these drugs. Human leukocyte antigen haplotype and Fcγ receptor polymorphisms are possible targets of the relevant research.
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125
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Mekki A, Dercle L, Lichtenstein P, Marabelle A, Michot JM, Lambotte O, Le Pavec J, De Martin E, Balleyguier C, Champiat S, Ammari S. Detection of immune-related adverse events by medical imaging in patients treated with anti-programmed cell death 1. Eur J Cancer 2018; 96:91-104. [PMID: 29698933 DOI: 10.1016/j.ejca.2018.03.006] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/01/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Programmed death receptor-1 blocking antibodies (anti-PD1) are a new standard of care in many cancer types. Patients benefit from improved survival but have the risk of immune-related adverse events (irAE). We evaluated if medical imaging procedures, used for anti-tumour response assessment, can detect irAEs. MATERIALS AND METHODS All consecutive patients treated with anti-PD1 and with a medical imaging acquisition performed within 2 weeks with irAEs ≥2 were retrospectively included. Data were gathered from June 2014 to February 2017, and a central review was performed. The primary and secondary end-points were i) to evaluate the overall detection rate of irAEs by medical imaging and ii) to provide a comprehensive radiological description of irAEs. RESULTS Fifty-three patients (31 women, 22 men; average age: 61 years) were included. The primary tumour was melanoma (n = 32), lung cancer (n = 18) and other (n = 3). Patients were treated with nivolumab (n = 27) or pembrolizumab (n = 26). Of 74 medical imaging procedures analysed (ratio = 1.4 medical imaging per patient), 55 irAE were detected. The detection rate was overall: 74% (95 confidence interval: 63-84%), positron emission tomography with 18F-fludeoxyglucose integrated with computed tomography (18F-FDG PET/CT): 83% (n = 10/12), magnetic resonance imaging: 83% (n = 5/6), computed tomography scan: 79% (n = 19/24), ultrasonography: 70% (n = 19/27), standard X-rays: 40% (n = 2/5), lung/mediastinum: 100% (n = 7/7), enterocolitis: 100% (n = 8/8), hypophysitis: 100% (n = 3/3), thyroiditis: 75% (n = 15/20), hepatitis: 67% (n = 2/3), arthralgia or arthritis: 40% (n = 2/5) and pancreas: 28% (n = 2/7). CONCLUSION Medical imaging detected 74% of irAE in patients treated with anti-PD1. Beyond response assessment, medical imaging can detect irAE and guide towards specific management. We described the most frequent sites and patterns of imaging findings.
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Affiliation(s)
- Ahmed Mekki
- Department of Radiology, Gustave Roussy Cancer Campus, Villejuif, France; Université Paris-Saclay, Paris, France.
| | - Laurent Dercle
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Cancer Campus, Villejuif, France; Université Paris-Saclay, Paris, France; Gustave Roussy, Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale (INSERM), U1015, Equipe Labellisée Ligue Nationale Contre le Cancer, Villejuif, F-94805, France; Department of Radiology, Columbia University Medical Center, NYC, NY, USA.
| | | | - Aurélien Marabelle
- Université Paris-Saclay, Paris, France; Gustave Roussy, Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale (INSERM), U1015, Equipe Labellisée Ligue Nationale Contre le Cancer, Villejuif, F-94805, France; Drug Development Department, Gustave Roussy, Villejuif, France
| | | | - Olivier Lambotte
- Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Service de Médecine Interne et Immunologie Clinique, F-94275, Le Kremlin-Bicêtre, France; INSERM U1184, Immunology of Viral Infections and Autoimmune Diseases, F-94276, Le Kremlin-Bicêtre, France; Université Paris Sud, UMR 1184, F-94276, Le Kremlin-Bicêtre, France; CEA, DSV/iMETI, IDMIT, F-92265, Fontenay-aux-Roses, France
| | - Jérôme Le Pavec
- Unité de Transplantation Pulmonaire, Service de Chirurgie Thoracique, Vasculaire et de Transplantation Cardio-Pulmonaire, France
| | | | - Corinne Balleyguier
- Department of Radiology, Gustave Roussy Cancer Campus, Villejuif, France; Université Paris-Saclay, Paris, France
| | | | - Samy Ammari
- Department of Radiology, Gustave Roussy Cancer Campus, Villejuif, France; Université Paris-Saclay, Paris, France
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126
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Carter BW, Bhosale PR, Yang WT. Immunotherapy and the role of imaging. Cancer 2018; 124:2906-2922. [PMID: 29671876 DOI: 10.1002/cncr.31349] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 12/21/2022]
Abstract
Significant advances in the genetic and molecular characterization of cancer have led to the development of effective immunotherapies. These therapeutics help the host immune system recognize cancer as foreign, promote the immune system, and relieve the inhibition that allows growth and spread of tumors. Experience with various immunotherapies, particularly the immunomodulatory monoclonal antibody ipilimumab, has demonstrated that unique patterns of response may be encountered that cannot be adequately captured by traditional response criteria, such as the World Health Organization (WHO) criteria and Response Evaluation Criteria in Solid Tumors (RECIST), which have been used primarily with cytotoxic chemotherapies. In response to these observations, several novel response criteria have been developed to evaluate patients who receive immunotherapy, including immune-related response criteria (irRC), immune-related RECIST (irRECIST), and immune RECIST (iRECIST). These criteria are typically used in conjunction with RECIST version 1.1 in the clinical trial setting, because approval of new therapeutics by the US Food and Drug Administration relies on the responses derived from RECIST version 1.1. Finally, a wide variety of immune-related adverse events may affect patients who receive immunotherapy, many of which can be identified on imaging studies such as computed tomography, magnetic resonance imaging, and 2-deoxy-2-(fluorine-18)fluoro-D-glucose-positron emission tomography/computed tomography. In this review, the authors present the role of imaging in the evaluation of patients treated with immunotherapy, including the background and application of irRC, irRECIST, and iRECIST; the imaging of immune-related adverse events; and future directions in advanced imaging of immunotherapy. Cancer 2018;124:2906-22. © 2018 American Cancer Society.
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Affiliation(s)
- Brett W Carter
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Priya R Bhosale
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wei T Yang
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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127
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Shroff GS, de Groot PM, Papadimitrakopoulou VA, Truong MT, Carter BW. Targeted Therapy and Immunotherapy in the Treatment of Non-Small Cell Lung Cancer. Radiol Clin North Am 2018; 56:485-495. [PMID: 29622080 DOI: 10.1016/j.rcl.2018.01.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The treatment strategy in advanced non-small cell lung cancer (NSCLC) has evolved from empirical chemotherapy to a personalized approach based on histology and molecular markers of primary tumors. Targeted therapies are directed at the products of oncogenic driver mutations. Immunotherapy facilitates the recognition of cancer as foreign by the host immune system, stimulates the immune system, and alleviates the inhibition that allows the growth and spread of cancer cells. The authors describes the role of targeted therapy and immunotherapy in the treatment of NSCLC, patterns of disease present on imaging studies, and immune-related adverse events encountered with immunotherapy.
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Affiliation(s)
- Girish S Shroff
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Patricia M de Groot
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Vassiliki A Papadimitrakopoulou
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Mylene T Truong
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Brett W Carter
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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128
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Kähler KC, Hassel JC, Heinzerling L, Loquai C, Mössner R, Ugurel S, Zimmer L, Gutzmer R. Management of side effects of immune checkpoint blockade by anti-CTLA-4 and anti-PD-1 antibodies in metastatic melanoma. J Dtsch Dermatol Ges 2018; 14:662-81. [PMID: 27373241 DOI: 10.1111/ddg.13047] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CTLA-4 and PD-1 are potential targets for tumor-induced downregulation of lymphocytic immune responses. Immune checkpoint-modifying monoclonal antibodies oppose these effects, inducing T cell-mediated immune responses to various tumors including melanoma. Both anti-CTLA-4 and anti-PD-1 antibodies modify the interaction between tumor, antigen-presenting cells, and T lymphocytes. With respect to overall survival, clinical studies have shown a major benefit for the anti-CTLA-4 antibody ipilimumab as well as the two anti-PD-1 antibodies nivolumab and pembrolizumab. Following approval of ipilimumab in 2011, the latter two achieved market authorization in the summer of 2015. Immune responses thus induced and enhanced inevitably entail autoimmune phenomena, affecting various organs to varying degrees. Knowledge of these side effects is crucial with regard to prevention and management by treating physicians. Typically occurring early on and presenting with pronounced and persistent diarrhea, colitis represents a major and severe side effect. Other immune-mediated disorders include dermatitis, hypophysitis, thyroiditis, hepatitis, iridocyclitis as well as other less common autoimmune phenomena. Early recognition and initiation of treatment can reduce risks and sequelae for patients. This review describes the mechanisms of action of immune checkpoint blockade as well as its clinical effects in metastatic melanoma, with a detailed focus on the spectrum of adverse events and their therapeutic management.
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Affiliation(s)
- Katharina C Kähler
- Department of Dermatology, Venereology, and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jessica C Hassel
- Department of Dermatology, and National Cancer Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Lucie Heinzerling
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Carmen Loquai
- Department of Dermatology, Medical Faculty, University of Mainz, Mainz, Germany
| | - Rotraut Mössner
- Department of Dermatology, Venereology, and Allergology, University Medicine Göttingen, Göttingen, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany
| | - Ralf Gutzmer
- Hanover Skin Cancer Center, Department of Dermatology, Venereology, and Allergology, Hanover Medical College, Hanover, Germany
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129
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Incidence and Management of Immune-Related Adverse Events in Patients Undergoing Treatment with Immune Checkpoint Inhibitors. Curr Oncol Rep 2018; 20:24. [PMID: 29511902 DOI: 10.1007/s11912-018-0671-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The unleashing of the immune system in an effort to fight cancer has proven to be an incredible advance in the war on cancer. However that breakthrough has come with a price in the form of serious and potentially fatal immune-related adverse events (irAEs). RECENT FINDINGS Rapid recognition and early intervention is imperative to avoid significant morbidity and mortality. Additionally, providers need to be aware that there are still new, rare, and long-term emerging irAEs that were not previously reported in clinical trials. Because of the significant difference between irAEs and those caused by chemotherapy and/or targeted therapy, providers must have a thorough understanding of which events would be considered immune related and require treatment. This review will cover descriptions of the most common and uncommon but serious irAEs experienced by patients on immunotherapy, as well as management of these irAEs.
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130
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A multidisciplinary approach to toxicity management of modern immune checkpoint inhibitors in cancer therapy. Melanoma Res 2018; 26:469-80. [PMID: 27306502 DOI: 10.1097/cmr.0000000000000273] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Immune-related Adverse Events (irAEs) are the most significant toxicities associated with the use of checkpoint inhibitors, and result from disinhibition of the host's immune homeostasis. The adverse effects experienced from immunotherapy are significantly different from those of chemotherapy and, to a lesser extent, targeted therapy. Early recognition and diagnosis of these toxicities is often challenging, but is critically important because of the potentially life-threatening nature and associated morbidity. Gastrointestinal, dermatologic, endocrine, and liver toxicities are the most commonly observed. Less commonly, the eyes, pancreas, kidneys, lungs, bone marrow, or nervous system may be affected. Although most irAEs may resolve with supportive care or discontinuation of drug, in severe cases, they may require hospitalization and immune suppressants, such as steroids, and/or may even cause death. The management of immune-related side effects requires a multidisciplinary approach.
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Sanjeevaiah A, Kerr T, Beg MS. Approach and management of checkpoint inhibitor-related immune hepatitis. J Gastrointest Oncol 2018; 9:220-224. [PMID: 29564187 PMCID: PMC5848041 DOI: 10.21037/jgo.2017.08.14] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/14/2017] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors have promising clinical activity across multiple gastrointestinal cancers and immune-mediated hepatotoxicity is particularly relevant for this group of patients. In this article we will review the recognition, workup and management of suspected checkpoint inhibitor related immune-hepatitis.
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Affiliation(s)
- Aravind Sanjeevaiah
- Division of Hematology and Medical Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, USA
- Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, USA
| | - Thomas Kerr
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, USA
| | - Muhammad Shaalan Beg
- Division of Hematology and Medical Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, USA
- Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, USA
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132
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Tian Y, Abu-Sbeih H, Wang Y. Immune Checkpoint Inhibitors-Induced Hepatitis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 995:159-164. [DOI: 10.1007/978-3-030-02505-2_8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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133
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Avigan MI, Muñoz MA. Perspectives on the Regulatory and Clinical Science of Drug-Induced Liver Injury (DILI). METHODS IN PHARMACOLOGY AND TOXICOLOGY 2018. [DOI: 10.1007/978-1-4939-7677-5_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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134
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Puzanov I, Diab A, Abdallah K, Bingham CO, Brogdon C, Dadu R, Hamad L, Kim S, Lacouture ME, LeBoeuf NR, Lenihan D, Onofrei C, Shannon V, Sharma R, Silk AW, Skondra D, Suarez-Almazor ME, Wang Y, Wiley K, Kaufman HL, Ernstoff MS. Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group. J Immunother Cancer 2017; 5:95. [PMID: 29162153 PMCID: PMC5697162 DOI: 10.1186/s40425-017-0300-z] [Citation(s) in RCA: 1280] [Impact Index Per Article: 182.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023] Open
Abstract
Cancer immunotherapy has transformed the treatment of cancer. However, increasing use of immune-based therapies, including the widely used class of agents known as immune checkpoint inhibitors, has exposed a discrete group of immune-related adverse events (irAEs). Many of these are driven by the same immunologic mechanisms responsible for the drugs' therapeutic effects, namely blockade of inhibitory mechanisms that suppress the immune system and protect body tissues from an unconstrained acute or chronic immune response. Skin, gut, endocrine, lung and musculoskeletal irAEs are relatively common, whereas cardiovascular, hematologic, renal, neurologic and ophthalmologic irAEs occur much less frequently. The majority of irAEs are mild to moderate in severity; however, serious and occasionally life-threatening irAEs are reported in the literature, and treatment-related deaths occur in up to 2% of patients, varying by ICI. Immunotherapy-related irAEs typically have a delayed onset and prolonged duration compared to adverse events from chemotherapy, and effective management depends on early recognition and prompt intervention with immune suppression and/or immunomodulatory strategies. There is an urgent need for multidisciplinary guidance reflecting broad-based perspectives on how to recognize, report and manage organ-specific toxicities until evidence-based data are available to inform clinical decision-making. The Society for Immunotherapy of Cancer (SITC) established a multidisciplinary Toxicity Management Working Group, which met for a full-day workshop to develop recommendations to standardize management of irAEs. Here we present their consensus recommendations on managing toxicities associated with immune checkpoint inhibitor therapy.
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Affiliation(s)
- I Puzanov
- Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| | - A Diab
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K Abdallah
- Merck & Co., Inc., Upper Gwynedd, PA, USA
| | - C O Bingham
- Johns Hopkins University, Baltimore, MD, USA
| | - C Brogdon
- Bristol-Myers Squibb Company, New York, NY, USA
| | - R Dadu
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L Hamad
- Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| | - S Kim
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M E Lacouture
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - N R LeBoeuf
- Dana Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - D Lenihan
- Washington University in St Louis, St Louis, MO, USA
| | - C Onofrei
- Indiana University, Indianapolis, IN, USA
| | - V Shannon
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Sharma
- Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| | - A W Silk
- Massachusetts General Hospital, Boston, MA, USA
| | - D Skondra
- University of Chicago, Chicago, IL, USA
| | | | - Y Wang
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K Wiley
- Oncology Nursing Society, Pittsburgh, PA, USA
| | - H L Kaufman
- Massachusetts General Hospital, Boston, MA, USA
| | - M S Ernstoff
- Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, 14263, USA.
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Aivazian K, Long GV, Sinclair EC, Kench JG, McKenzie CA. Histopathology of pembrolizumab-induced hepatitis: a case report. Pathology 2017; 49:789-792. [PMID: 29079004 DOI: 10.1016/j.pathol.2017.07.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/02/2017] [Accepted: 07/08/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Karina Aivazian
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Australia.
| | - Georgina V Long
- Melanoma Institute Australia, Australia; University of Sydney, Australia; Royal North Shore Hospital, Australia
| | | | - James G Kench
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Australia; University of Sydney, Australia
| | - Catriona A McKenzie
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Australia; University of Sydney, Australia
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Gordon R, Kasler MK, Stasi K, Shames Y, Errante M, Ciccolini K, Skripnik Lucas A, Raasch P, Fischer-Cartlidge E. Checkpoint Inhibitors: Common Immune-Related Adverse Events and Their Management
. Clin J Oncol Nurs 2017; 21:45-52. [PMID: 28315555 DOI: 10.1188/17.cjon.s2.45-52] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Immunotherapy, specifically the use of checkpoint inhibitors, offers patients with cancer an alternative to chemotherapy, targeting different pathways to destroy cancer cells. The side effects of immunotherapies, as well as their impact on normal tissue, need to be assessed and managed based on their mechanisms of action. OBJECTIVES This article presents an overview of immune-related adverse events (AEs).
. METHODS Common immune-related toxicities, as well as rare and refractory toxicities, are reviewed.
. FINDINGS Immunotherapy treatment is an option for many patients with cancer, and nurses must understand the distinct side effect profile of these agents. Prompt identification and expert management are the cornerstones of success when dealing with immune-related AEs, and oncology nurses play a key role in improving patient care.
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Solinas C, Porcu M, Hlavata Z, De Silva P, Puzzoni M, Willard-Gallo K, Scartozzi M, Saba L. Critical features and challenges associated with imaging in patients undergoing cancer immunotherapy. Crit Rev Oncol Hematol 2017; 120:13-21. [PMID: 29198327 DOI: 10.1016/j.critrevonc.2017.09.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 09/13/2017] [Accepted: 09/30/2017] [Indexed: 01/03/2023] Open
Abstract
Manipulating an individual's immune system through immune checkpoint blockade is revolutionizing the paradigms of cancer treatment. Peculiar patterns and kinetics of response have been observed with these new drugs, rendering the assessment of tumor burden particularly challenging in cancer immunotherapy. The mechanisms of action for immune checkpoint blockade, based upon engagement of the adaptive immune system, can generate unusual response patterns, including pseudoprogression, hyperprogression, atypical and delayed responses. In patients treated with immune checkpoint blockade and radiotherapy, a reduction in tumor burden at metastatic sites distant from the irradiation field (abscopal effect) has been observed, with synergistic systemic immune effects provoked by this combination. New toxicities have also been observed, due to excessive immune activity in several organs, including lung, colon, liver and endocrine glands. Efforts to standardize assessment of cancer immunotherapy responses include novel consensus guidelines derived by modifying World Health Organization (WHO) and Response Evaluation Criteria In Solid Tumors (RECIST) criteria. The aim of this review is to evaluate imaging techniques currently used routinely in the clinic and those being used as investigational tools in immunotherapy clinical trials.
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Affiliation(s)
- Cinzia Solinas
- Molecular Immunology Unit, Institut Jules Bordet and Université Libre de Bruxelles, Boulevard de Waterloo, n. 127, Brussels, Belgium
| | - Michele Porcu
- Department of Radiology, Azienda Ospedaliero Universitaria of Cagliari, SS 554 Monserrato, CA, Italy.
| | - Zuzana Hlavata
- Department of Medical Oncology, CHR Mons - Hainaut, Avenue Baudouin de Constantinople, n. 5, Mons, Hainaut, Belgium
| | - Pushpamali De Silva
- Molecular Immunology Unit, Institut Jules Bordet and Université Libre de Bruxelles, Boulevard de Waterloo, n. 127, Brussels, Belgium
| | - Marco Puzzoni
- Department of Medical Oncology, Azienda Ospedaliero Universitaria of Cagliari, SS 554 Monserrato, CA, Italy
| | - Karen Willard-Gallo
- Molecular Immunology Unit, Institut Jules Bordet and Université Libre de Bruxelles, Boulevard de Waterloo, n. 127, Brussels, Belgium
| | - Mario Scartozzi
- Department of Medical Oncology, Azienda Ospedaliero Universitaria of Cagliari, SS 554 Monserrato, CA, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria of Cagliari, SS 554 Monserrato, CA, Italy
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138
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Doherty GJ, Duckworth AM, Davies SE, Mells GF, Brais R, Harden SV, Parkinson CA, Corrie PG. Severe steroid-resistant anti-PD1 T-cell checkpoint inhibitor-induced hepatotoxicity driven by biliary injury. ESMO Open 2017; 2:e000268. [PMID: 29081991 PMCID: PMC5652580 DOI: 10.1136/esmoopen-2017-000268] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 09/19/2017] [Accepted: 09/20/2017] [Indexed: 12/14/2022] Open
Abstract
Introduction Hepatotoxicity from T-cell checkpoint blockade is an increasingly common immune-related adverse event, but remains poorly characterised and can be challenging to manage. Such toxicity is generally considered to resemble autoimmune hepatitis, although this assumption is extrapolated from limited clinicopathological reports of anti-cytotoxic T-lymphocyte-associated protein 4-induced hepatotoxicity. Methods Here we report, with full clinicopathological correlation, three cases of T-cell checkpoint inhibitor-induced hepatotoxicity associated with anti-programmed cell death protein 1 agents. Results We find that a major feature of these cases is biliary injury, including a unique case of vanishing bile duct syndrome, and that such toxicity was poorly responsive to long-term immunosuppression (corticosteroids and mycophenolate mofetil). Any potential benefits of long-term immunosuppression in these cases were outweighed by therapy-related complications. Discussion We discuss potential aetiologies and risk factors for immune-mediated biliary toxicity in the context of the limited literature in this field, and provide guidance for the investigation and supportive management of affected patients.
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Affiliation(s)
- Gary Joseph Doherty
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Adam M Duckworth
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Susan E Davies
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - George F Mells
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Rebecca Brais
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Susan V Harden
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christine A Parkinson
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Pippa G Corrie
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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139
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Jazieh AR, Al Kattan K, Bamousa A, Al Olayan A, Abdelwarith A, Ansari J, Al Twairqi A, Al Fayea T, Al Saleh K, Al Husaini H, Abdelhafiez N, Mahrous M, Faris M, Al Omair A, Hebshi A, Al Shehri S, Al Dayel F, Bamefleh H, Khalbuss W, Al Ghanem S, Loutfi S, Khankan A, Al Rujaib M, Al Ghamdi M, Ibrahim N, Swied A, Al Kayait M, Datario M. Saudi lung cancer management guidelines 2017. Ann Thorac Med 2017; 12:221-246. [PMID: 29118855 PMCID: PMC5656941 DOI: 10.4103/atm.atm_92_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 06/09/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lung cancer management is getting more complex due to the rapid advances in all aspects of diagnostic and therapeutic options. Developing guidelines is critical to help practitioners provide standard of care. METHODS The Saudi Lung Cancer Guidelines Committee (SLCGC) multidisciplinary members from different specialties and from various regions and healthcare sectors of the country reviewed and updated all lung cancer guidelines with appropriate labeling of level of evidence. Supporting documents to help healthcare professionals were developed. RESULTS Detailed lung cancer management guidelines were finalized with appropriate resources for systemic therapy and short reviews highlighting important issues. Stage based disease management recommendation were included. A summary explanation for complex topics were included in addition to tables of approved systemic therapy. CONCLUSION A multidisciplinary lung cancer guidelines was developed and will be disseminated across the country.
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Affiliation(s)
| | - Abdul Rahman Jazieh
- Department of Medical Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khaled Al Kattan
- Department of Surgery, Al Faisal University, Riyadh, Saudi Arabia
| | - Ahmed Bamousa
- Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ashwaq Al Olayan
- Department of Medical Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ahmed Abdelwarith
- Department of Medical Oncology, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Jawaher Ansari
- Department of Medical Oncology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah Al Twairqi
- Department of Medical Oncology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Turki Al Fayea
- Department of Medical Oncology, Princess Noorah Oncology Center, Riyadh, Saudi Arabia
| | - Khalid Al Saleh
- Department of Medical Oncology, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Hamed Al Husaini
- Department of Medical Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nafisa Abdelhafiez
- Department of Medical Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mervat Mahrous
- Department of Medical Oncology, King Fahad Hospital, Madinah, Saudi Arabia
| | - Medhat Faris
- Department of Medical Oncology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ameen Al Omair
- Department of Radiation Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Adnan Hebshi
- Department of Radiation Oncology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Salem Al Shehri
- Department of Radiation Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Foad Al Dayel
- Department of Pathology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hanaa Bamefleh
- Department of Pathology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Walid Khalbuss
- Department of Pathology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Sarah Al Ghanem
- Department of Radiology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Shukri Loutfi
- Department of Radiology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Azzam Khankan
- Department of Interventional Radiology, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Meshael Al Rujaib
- Department of Radiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majed Al Ghamdi
- Department of Pulmonary, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nagwa Ibrahim
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdulmonem Swied
- Department of Gastroenterology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohammad Al Kayait
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Marie Datario
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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140
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Widmann G, Nguyen VA, Plaickner J, Jaschke W. Imaging Features of Toxicities by Immune Checkpoint Inhibitors in Cancer Therapy. CURRENT RADIOLOGY REPORTS 2017; 5:59. [PMID: 28959504 PMCID: PMC5594046 DOI: 10.1007/s40134-017-0256-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of review With the increasing use of immune checkpoint inhibitors in cancer therapy radiographic profiling of frequent and serious immune-related adverse events (irAEs) becomes more relevant. This article reviews imaging features of irAEs induced by the anti-CTLA-4 and anti-PD-1 antibodies ipilimumab, nivolumab and pembrolizumab. Recent findings Important radiological manifestations are immune-related colitis, hepatitis, pancreatitis, hypophysitis, pneumonitis, arthritis and sarcoid-like lymphadenopathy. Typical imaging features are summarized and compared with other relevant differential diagnoses. Summary Early diagnosis and appropriate therapeutic decisions are required for a successful treatment of irAEs. In addition to staging and follow-up imaging, identification and monitoring of adverse events becomes an important radiologic aspect in oncologic care.
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Affiliation(s)
- Gerlig Widmann
- Department of Radiology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Van Anh Nguyen
- Department of Dermatology, Venereology and Allergology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Julian Plaickner
- Department of Radiology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Werner Jaschke
- Department of Radiology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
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141
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Hahn AW, Gill DM, Agarwal N, Maughan BL. PD-1 checkpoint inhibition: Toxicities and management. Urol Oncol 2017; 35:701-707. [PMID: 28889921 DOI: 10.1016/j.urolonc.2017.08.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/02/2017] [Accepted: 08/07/2017] [Indexed: 12/31/2022]
Abstract
PURPOSE With the recent approval of 5 PD-1/PD-L1 inhibitors for a number of malignancies, PD-1 axis inhibition is drastically changing the treatment landscape of immunotherapy in cancer. As PD-1/PD-L1 are involved in peripheral immune tolerance, inhibition of this immune checkpoint has led to novel immune-related adverse events including colitis, hepatitis, pneumonitis, rash, and endocrinopathies among many others. MATERIALS AND METHODS In this seminar, we will analyze the incidence of immune-related adverse events for nivolumab, pembrolizumab, atezolizumab, durvalumab, and avelumab. Then, we will discuss the specific management of the most common immune-mediated adverse events including colitis, hepatitis, pneumonitis, rash, endocrinopathies, nephritis, and neurologic toxicities. RESULTS Immune-related adverse events are frequently treated with immunosuppressive medication such as steroids and mycofenolate mofetil. CONCLUSIONS There are specific immune-related adverse events which are frequently seen by the treating oncologist from checkpoint inhibitors. It is essential to understand the recommended treatment options to minimize toxicity and mortality from this important class of anti-neoplastic therapies.
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Affiliation(s)
- Andrew W Hahn
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - David M Gill
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Neeraj Agarwal
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Benjamin L Maughan
- Department of Internal Medicine, University of Utah, Salt Lake City, UT.
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142
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Simonelli M, Di Tommaso L, Baretti M, Santoro A. Pathological characterization of nivolumab-related liver injury in a patient with glioblastoma. Immunotherapy 2017; 8:1363-1369. [PMID: 28000537 DOI: 10.2217/imt-2016-0057] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Immune checkpoint inhibitors such as anti-CTLA-4 and anti-PD-1/PD-L1 monoclonal antibodies have dramatically changed the paradigm of cancer therapy over the past few years. The use of these agents is associated with a unique pattern of autoimmune-like/inflammatory side effects termed immune-related adverse events (irAEs), that may cause collateral damage to normal tissues. Although severe irAEs remain rare, they can become life-threatening if not anticipated and managed appropriately. Improving our knowledge of the mechanisms underlying the development of these toxicities is crucial to optimize clinical efficacy and safety of these new immunotherapeutics. Herein we describe for the first time the pathological features of a severe liver-injury associated with the administration of the anti-PD-1 agent nivolumab in a patient with glioblastoma.
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Affiliation(s)
- Matteo Simonelli
- Humanitas Cancer Center, Humanitas Clinical & Research Center, Via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Luca Di Tommaso
- Department of Pathology, Humanitas Clinical & Research Center, Via Manzoni 56, 20089 Rozzano (Mi), Italy.,Humanitas University, Via Alessandro Manzoni 113, 20089 Rozzano (Mi), Italy
| | - Marina Baretti
- Humanitas Cancer Center, Humanitas Clinical & Research Center, Via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Armando Santoro
- Humanitas Cancer Center, Humanitas Clinical & Research Center, Via Manzoni 56, 20089 Rozzano (Mi), Italy.,Humanitas University, Via Alessandro Manzoni 113, 20089 Rozzano (Mi), Italy
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143
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Abstract
The use of immune checkpoint inhibitors (ICI) in several cancers is expanding; however, their use in patients with cancer and an organ transplant is very limited. In this review, we summarize the literature and the experience of anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and anti-programmed cell death protein 1 (PD-1) inhibitors in the organ transplant patient. The immunology of CTLA-4 and PD-1 inhibitors and their role in tolerance breakdown is also reviewed. While CTLA-4 inhibitors have been successfully used in kidney, liver, and heart transplant patients without rejection, the uses of PD-1 inhibitors and the combination therapy of CTLA-4 and PD-1 inhibitors have been associated with cellular- and antibody-mediated rejection. While immunosuppression minimization is needed for ICI to provide the best response when managing transplant patients who develop malignancy, this can lead to rejection episodes. Prevention strategies, such as the use of ongoing steroids and sirolimus, could prevent rejection while sustaining tumor response. As the experience grows with these agents, we will learn more about tolerance and the use of ICI in the organ transplant patient. Therefore, the use of an immune checkpoint blockade in transplantation is extremely difficult, and future research should focus on finding the right balance between unleashing the immune system to provide an anti-tumor effect but at the same time sustaining tolerance so that rejection is suppressed. Also, the ability to identify biomarkers that may predict rejection early and allow for the fine tuning of doses and frequencies of drug administration would be very helpful.
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144
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Haanen JBAG, Carbonnel F, Robert C, Kerr KM, Peters S, Larkin J, Jordan K. Management of toxicities from immunotherapy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28:iv119-iv142. [PMID: 28881921 DOI: 10.1093/annonc/mdx225] [Citation(s) in RCA: 1415] [Impact Index Per Article: 202.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- J B A G Haanen
- Netherlands Cancer Institute, Division of Medical Oncology, Amsterdam, The Netherlands
| | - F Carbonnel
- Department of Gastroenterology, Kremlin Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - C Robert
- Department of Medicine, Dermatology Unit, Gustave Roussy Cancer Campus, Villejuif, France
| | - K M Kerr
- Department of Pathology, Aberdeen University Medical School & Aberdeen Royal Infirmary, Aberdeen, UK
| | - S Peters
- Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - J Larkin
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University Hospital of Heidelberg, Heidelberg, Germany
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145
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Arora N, Gupta A, Singh PP. Biological agents in gastrointestinal cancers: adverse effects and their management. J Gastrointest Oncol 2017; 8:485-498. [PMID: 28736636 DOI: 10.21037/jgo.2017.01.07] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Biological therapy comprises agents that by virtue of their unique mechanisms of action, are able to specifically incite a response against or target malignant cells. They differ from conventional chemotherapy with regard to mechanisms of action, indications and side effect profile. Biologic agents have revolutionized therapy for a number of malignancies. In the setting of gastrointestinal (GI) malignancies, agents targeting vascular endothelial growth factor (VEGF), human epidermal growth factor receptor 2 (Her2/Neu) and epidermal growth factor receptor (EGFR) have proven to be invaluable additions to chemotherapy. However, these agents bring with them a set of side effects attributable to their unique mechanisms of action. The anti VEGF agents-bevacizumab, aflibercept and ramucirumab, can result in renal and vascular complications such as hypertension, arterial thrombotic events (ATE), proteinuria and GI perforations. The anti EGFR agents classically cause dermatological toxicities, in addition to hypomagnesemia, which can be dose limiting for patients. Trastuzumab, a monoclonal antibody that targets Her2/Neu, is known to cause cardiotoxicity, especially when used with anthracyclines. Use of immunotherapy agents such as nivolumab is associated with the development immune related adverse events (irAEs). The use of these agents is expected to increase over the next few years and it is crucial that patients and practitioners are aware of their adverse effects and current management strategies. This review highlights the adverse events associated with the use of biologic and immunologic therapies in GI cancers, their incidence and current management strategies.
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Affiliation(s)
- Nivedita Arora
- Department of Internal Medicine, University of Texas Southwestern Medical Centre, Dallas, TX, USA
| | - Arjun Gupta
- Department of Internal Medicine, University of Texas Southwestern Medical Centre, Dallas, TX, USA
| | - Preet Paul Singh
- Division of Hematology/Oncology, Springfield Clinic Cancer Center, Springfield, Illinois, USA
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146
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Abstract
Ipilimumab is a monoclonal antibody that exerts its effects by inhibiting the cytotoxic T-lymphocyte-associated protein 4 receptor on cytotoxic T lymphocytes. It is frequently used for the treatment of unresectable or metastatic melanoma. Ipilimumab may lead to several immune-related disease including colitis, thyroiditis, pneumonia, hepatitis, or pancreatitis as a side effect. Limited number of cases with hepatic damage as an ipilimumab-related adverse event has been reported in the literature. This agent has been implicated in causing acute hepatitis-like liver injury. Here, we presented a case in which cholestatic hepatitis developed during ipilimumab use for the treatment of metastatic melanoma.
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147
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Pathogenesis, clinical manifestations and management of immune checkpoint inhibitors toxicity. TUMORI JOURNAL 2017; 103:405-421. [PMID: 28497847 DOI: 10.5301/tj.5000625] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors have emerged as an effective treatment for several tumor types and their use in clinical practice is expected to further increase in the immediate future. Although these agents are well tolerated, they are associated with a peculiar spectrum of toxicity, which is immune mediated and may potentially affect every organ. However, immune-related adverse events are mostly reversible if promptly diagnosed and adequately treated. Therefore, it is crucial that medical oncologists know how to diagnose and treat immune-related adverse events. This review focuses on the pathogenesis, clinical manifestations and management of immune-related toxicity of anti-CTLA-4 and anti-PD-1 antibodies.
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148
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Alessandrino F, Tirumani SH, Krajewski KM, Shinagare AB, Jagannathan JP, Ramaiya NH, Di Salvo DN. Imaging of hepatic toxicity of systemic therapy in a tertiary cancer centre: chemotherapy, haematopoietic stem cell transplantation, molecular targeted therapies, and immune checkpoint inhibitors. Clin Radiol 2017; 72:521-533. [PMID: 28476244 DOI: 10.1016/j.crad.2017.04.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/28/2017] [Accepted: 04/03/2017] [Indexed: 12/13/2022]
Abstract
The purpose of this review is to familiarise radiologists with the spectrum of hepatic toxicity seen in the oncology setting, in view of the different systemic therapies used in cancer patients. Drug-induced liver injury can manifest in various forms, and anti-neoplastic agents are associated with different types of hepatotoxicity. Although chemotherapy-induced liver injury can present as hepatitis, steatosis, sinusoidal obstruction syndrome, and chronic parenchymal damages, molecular targeted therapy-associated liver toxicity ranges from mild liver function test elevation to fulminant life-threatening acute liver failure. The recent arrival of immune checkpoint inhibitors in oncology has introduced a new range of immune-related adverse events, with differing mechanisms of liver toxicity and varied imaging presentation of liver injury. High-dose chemotherapy regimens for haematopoietic stem cell transplantation are associated with sinusoidal obstruction syndrome. Management of hepatic toxicity depends on the clinical scenario, the drug in use, and the severity of the findings. In this article, we will (1) present the most common types of oncological drugs associated with hepatic toxicity and associated liver injuries; (2) illustrate imaging findings of hepatic toxicities and the possible differential diagnosis; and (3) provide a guide for management of these conditions.
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Affiliation(s)
- F Alessandrino
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - S H Tirumani
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - K M Krajewski
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - A B Shinagare
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - J P Jagannathan
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - N H Ramaiya
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - D N Di Salvo
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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149
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Bourke JM, O'Sullivan M, Khattak MA. Management of adverse events related to new cancer immunotherapy (immune checkpoint inhibitors). Med J Aust 2017; 205:418-424. [PMID: 27809739 DOI: 10.5694/mja16.00586] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/20/2016] [Indexed: 12/19/2022]
Abstract
New immunotherapies have significantly improved survival in certain advanced cancers in recent years, particularly metastatic melanoma and lung cancer. The most effective of these therapies are the immune checkpoint inhibitors (ICIs) such as ipilimumab, nivolumab and pembrolizumab. The use of ICIs will continue to increase in the coming years as evidence of their benefit in a range of other cancers builds. ICIs are associated with novel immune-related adverse events (irAEs), which can involve a wide range of organs. The most common irAEs involve the skin (rash, pruritus), gastrointestinal tract (diarrhoea, colitis) and endocrine system (thyroid, pituitary). While severity is generally mild, life-threatening complications can occur if not recognised and treated promptly. Due to the diverse manifestations of irAEs, patients may present to doctors who are not familiar with these drugs, which creates the potential for delays in management. Management of irAEs depends on severity and the organ affected. Systemic steroids are often required and ICI therapy may be withheld or discontinued. Additional immunosuppressive medications may be necessary in steroid-refractory cases. This review provides an overview of the potential toxicities and their management for general clinicians. Broader awareness of these issues among medical professionals will hopefully reduce unnecessary delays in diagnosis and treatment. Patient and carer education regarding irAEs is extremely important; patients and carers should be advised to seek urgent medical attention if required.
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The Advantages and Challenges of Using FDG PET/CT for Response Assessment in Melanoma in the Era of Targeted Agents and Immunotherapy. Eur J Nucl Med Mol Imaging 2017; 44:67-77. [DOI: 10.1007/s00259-017-3691-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 12/15/2022]
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