Programmed Cell Death-1 Inhibitor-Induced Type 1 Diabetes Mellitus

Immune Checkpoint Blockade Anti-PD-L1 as a Trigger for Autoimmune Polyendocrine Syndrome

Context

The programmed cell death protein 1 (PD-1)/programmed cell death protein ligand 1 (PD-L1) pathway is a key regulator in T-cell activation and tolerance, limiting effector T-cell function in peripheral tissues. Atezolizumab, an anti–PD-L1 monoclonal antibody, is approved for treatment of some types of advanced cancer. Its main treatment-related adverse events are immune related, such as thyroid dysfunction and hypophysitis. Autoimmune endocrinopathy can occur as isolated manifestations; only a few cases of autoimmune polyendocrine syndromes have been reported thus far.

Case

We report a case of polyendocrine syndrome type 2, characterized by Addison disease (AD), type 1 diabetes mellitus (T1DM), accompanied by hypophysitis, in a patient treated with atezolizumab. Testing was positive for 21-hydroxylase and pituitary antibodies and negative for islet cells antibodies. HLA typing revealed DRB1*04 and DQB1*03 haplotypes, which are associated with increased susceptibility to T1DM and AD.

Conclusion

The type and severity of immune-related adverse events in polyendocrine syndrome type 2 are different and depend on the monoclonal antibody used. Although the numerous molecular mechanisms inducing autoimmune endocrine diseases are still unclear, a link exists between HLA haplotypes, gene variants involved in immune checkpoint molecule expression, and increased susceptibility to autoimmune endocrinopathies. Additional studies are needed to identify susceptible patients and adapt therapy to each patient.

Cytokines, Chemokines, and Other Biomarkers of Response for Checkpoint Inhibitor Therapy in Skin Cancer

Immunotherapy for skin malignancies has ushered in a new era for cancer treatments by demonstrating unprecedented durable responses in the setting of metastatic Melanoma. Consequently, checkpoint inhibitors are now the first-line treatment of metastatic melanoma and widely used as adjuvant therapy for stage III disease. With the observation that higher tumor mutational burden correlates with a better response, checkpoint inhibitors are tested in other skin cancer types of known high tumor mutational burden with promising results and recently became the first-ever FDA-approved treatment for metastatic Merkel cell carcinoma. The emerging new standards-of-care will necessitate more precise biomarkers and predictors for treatment response and immune-related adverse events. Measurable immune-related mediators are currently under investigation as factors that promote or block the response to cancer immunotherapy and may provide insights into the underlying immune response to the tumor. Cytokines and chemokines are such mediators and are crucial for facilitating the recruitment and activation of specific subsets of leukocytes within the microenvironment of skin cancers. The exact mechanisms of how these meditators, both immunological and non-immunological, operate in the tumor microenvironment is an area of active research, so to reliable biomarkers of responses to cancer immunotherapy. Here, we will review and summarize the expanding body of literature for immune-related biomarkers pertaining to Melanoma, Basal cell carcinoma, Squamous cell carcinoma, and Merkel cell carcinoma, highlighting clinically relevant checkpoint inhibitor therapy biomarker advancements.

Anti-PD-1 pembrolizumab induced autoimmune diabetes in Chinese patient: A case report

RATIONALE

Programmed cell death-1 protein (PD-1) antibody is an immune-checkpoint inhibitor that triggers anti-tumor response by enhancing immune response. Although PD-1 antibody has been reported effective in some malignant tumor, it can also induce significant immune-related adverse events (irAEs) such as autoimmune diabetes.

PATIENT CONCERNS

A 67-year-old male patient with non-small cell lung cancer (NSCLS) presented with polydipsia, polyuria, weakness, and weight loss after use of anti-programmed cell death-1 antibody therapy. Hyperglycemia, high serum ketone, low bicarbonate and high anion gap were compatible with the criteria of diabetic ketoacidosis (DKA).

DIAGNOSES

Autoimmune diabetes and diabetic ketoacidosis (DKA). The presence of low serum titers of c-peptide, high blood glucose together with diabetic ketoacidosis (DKA) that occurs shortly after the use of pembrolizumab strongly supported the diagnosis of anti-PD-1 induced autoimmune diabetes.

INTERVENTIONS

The patient stopped using pembrolizumab while continuous subcutaneous insulin infusion (CSII) was started at the same time. The insulin infusion was switched to multiple daily injection (MDI) after he was discharged from hospital.

OUTCOMES

The patient is now a well-controlled insulin-dependent patient with palliative care of NSCLS.

LESSONS

Autoimmune diabetes induced by anti-programmed cell death-1 (PD-1)/programmed cell death 1 ligand 1 (PD-L1) therapy is a rare, but life threatening immune-related side effect. Physicians should closely monitor diabetes-related indexes of patients who have been undergoing the treatment of anti-PD-1/PD-L1 therapy.

PD-1 Inhibitor Immune-Related Adverse Events in Patients With Preexisting Endocrine Autoimmunity

CONTEXT

Immune checkpoint inhibitors, including monoclonal antibodies directed against programmed cell death protein 1 (PD-1) and its ligand, have emerged as beneficial cancer immunotherapies. These therapies are known to cause immune-related side effects; however, their role in patients with a preexisting autoimmune disease is not clear.

CASE DESCRIPTION

We describe two cases of anti-PD-1 immune-related adverse events. A 52-year-old male with longstanding type 1 diabetes (T1D), long-term stable kidney transplant, and hypothyroidism received two separate anti-PD-1 monoclonal antibodies for metastatic melanoma. The patient developed acute kidney graft rejection requiring hemodialysis and worsening of autoimmune hypothyroidism 3 weeks after starting treatment. He continued anti-PD-1 treatments and remained on hemodialysis and increased levothyroxine dosage. The second case is a 62-year-old male with no previous history of diabetes who received anti-PD-1 treatment and developed severe diabetic ketoacidosis (DKA) 5 days following the start of therapy. Further laboratory testing revealed high titer antibodies directed against glutamic acid decarboxylase. These antibodies, which were of the IgG isotype and involved in memory immune responses, were likely present before anti-PD-1 treatment. He also had human leukocyte antigen genes that confer T1D genetic risk. Despite normal pretreatment blood glucose levels and HbA1c, the patient requires permanent exogenous insulin treatment.

CONCLUSION

Patients with preexisting endocrine autoimmunity may have more frequent and severe immune-related side effects with anti-PD-1 treatment. Given the morbidity and mortality associated with solid organ transplant rejection and DKA, clinicians caring for patients receiving these state-of-the-art therapies need to be aware of the potential adverse events.