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Polyradiculoneuropathy induced by immune checkpoint inhibitors: a case series and review of the literature. J Neurol 2020; 268:680-688. [PMID: 32909093 DOI: 10.1007/s00415-020-10213-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/29/2020] [Accepted: 09/02/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The purpose of the present study is to report the clinical characteristics of polyradiculoneuropathy induced by immune checkpoint inhibitors (ICIs). METHODS We retrospectively reviewed lists of all inpatients with neurological immune-related adverse events (irAEs) treated at the neurology departments of three hospitals in January 2017 and December 2019. We also performed a review of the previous case reports with polyradiculoneuropathy induced by ICI therapy. RESULTS We had 4 patients with polyradiculoneuropathy following ICI therapy. We comprehensively reviewed our 4 patients and 32 previous case reports. There were 28 men and 8 women with a mean onset age of 61 years. ICI monotherapy was performed in 27 patients, whereas the combination of ICIs was administered in 9 patients. All patients except 2 showed limb weakness, which was observed symmetrically and predominantly in the legs rather than the arms. Bulbar involvement was observed in 7 patients. The laboratory findings were demyelination in electrophysiological studies and elevated protein with lymphocytes in the cerebrospinal fluid. Disease severity was ranked on the Hughes functional scale; 17 patients were grade 4 or greater. The treatment responses to corticosteroid and intravenous methylprednisolone were favorable. Intravenous immunoglobulin was also used in combination with steroids. Seven patients died, including 4 who on mechanical ventilation. CONCLUSION Polyradiculoneuropathy induced by ICIs has a distinct subset of neurological irAEs and requires early recognition.
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Fan S, Ren H, Zhao L, Yin J, Feng G, Wang J, Guan H. Neurological immune‐related adverse events associated with immune checkpoint inhibitors: A review of the literature. Asia Pac J Clin Oncol 2020; 16:291-298. [PMID: 32893999 DOI: 10.1111/ajco.13375] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 05/05/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Luo Zhao
- Department of Thoracic Surgery, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Jian Yin
- Department of Neurology Beijing Hospital Beijing China
| | - Guodong Feng
- Department of Neurology, Zhongshan Hospital Fudan University Shanghai China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital Capital Medical University Beijing China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
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Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of immune-mediated cardiovascular, rheumatic, and renal toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6159-6173. [PMID: 32856212 DOI: 10.1007/s00520-020-05710-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as the newest pillar of cancer treatment. Immune-mediated toxicities, stemming from increased activity within the T cell lineage, range from asymptomatic or mild complications to those that are fulminant and potentially fatal. Although they are of variable occurrence, cardiovascular, rheumatic, and renal immune-mediated toxicities are among the most serious of these adverse events. We present MASCC recommendations with respect to the workup and management of cardiovascular, rheumatic, and renal immune-mediated toxicities with a focus on presentations that require treatment with immunomodulating agents.
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Yao S, Li X, Nong J, Zhang Y. [Immune Checkpoint Inhibitors-induced Myasthenia Gravis: From Diagnosis to Treatment]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2020; 23:685-688. [PMID: 32752585 PMCID: PMC7467994 DOI: 10.3779/j.issn.1009-3419.2020.102.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
已经证实免疫检查点抑制剂(immune checkpoint inhibitor, ICI)使多种肿瘤的治疗有了翻天覆地的变化。尽管治疗的有效性让人欣慰,但是这些治疗也造成了多样化的免疫治疗相关的不良反应(immune-related adverse events, irAEs)。重症肌无力(myasthenia gravis, MG)就是一种罕见且危及生命的irAE,通常在ICI治疗后急性发病并迅速进展。早期诊断和积极的治疗非常重要。在此,我们对近几年的相关文献进行了复习和整理,针对ICI-MG诊断和治疗相关的常见问题提供参考意见。
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Affiliation(s)
- Shuyang Yao
- Department of Thoracic Surgery, Xuanwu Hospital, Diagnostic and Treatment Centers of Lung Cancer, Capital Medical University, Beijing 100053, China
| | - Xiaoxue Li
- Department of Thoracic Surgery, Xuanwu Hospital, Diagnostic and Treatment Centers of Lung Cancer, Capital Medical University, Beijing 100053, China
| | - Jingying Nong
- Department of Thoracic Surgery, Xuanwu Hospital, Diagnostic and Treatment Centers of Lung Cancer, Capital Medical University, Beijing 100053, China
| | - Yi Zhang
- Department of Thoracic Surgery, Xuanwu Hospital, Diagnostic and Treatment Centers of Lung Cancer, Capital Medical University, Beijing 100053, China
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Sechi E, Markovic SN, McKeon A, Dubey D, Liewluck T, Lennon VA, Lopez-Chiriboga AS, Klein CJ, Mauermann M, Pittock SJ, Flanagan EP, Zekeridou A. Neurologic autoimmunity and immune checkpoint inhibitors: Autoantibody profiles and outcomes. Neurology 2020; 95:e2442-e2452. [PMID: 32796130 DOI: 10.1212/wnl.0000000000010632] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/27/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To describe neural autoantibody profiles and outcomes in patients with neurologic autoimmunity associated with immune checkpoint inhibitor (ICI) cancer immunotherapy. METHODS In this retrospective descriptive study, 63 patients with ICI-related neurologic autoimmunity were included: 39 seen at the Mayo Clinic Neurology Department (clinical cohort) and 24 whose serum/CSF was referred to the Mayo Clinic Neuroimmunology Laboratory for autoantibody testing. Serum/CSF samples were tested for neural-specific autoantibodies. Predictors of unfavorable outcome (residual adverse event severity grade ≥3) were explored (logistic regression). RESULTS Median age at neurologic symptom onset was 65 years (range 31-86); 40% were female. Neurologic manifestations were CNS-restricted (n = 26), neuromuscular (n = 30), combined (n = 5), or isolated retinopathy (n = 2). Neural-specific autoantibodies were common in patients with CNS involvement (7/13 [54%] in the unbiased clinical cohort) and included known or unidentified neural-restricted specificities. Only 11/31 patients with CNS manifestations had neuroendocrine malignancies typically associated with paraneoplastic autoimmunity. Small-cell lung cancer (SCLC)-predictive antibodies were seen in 3 patients with non-neuroendocrine tumors (neuronal intermediate filament immunoglobulin G [IgG] and antineuronal nuclear antibody 1 with melanoma; amphiphysin IgG with non-SCLC). A median of 10 months from onset (range, 0.5-46), 14/39 in the clinical cohort (36%) had unfavorable outcomes; their characteristics were age ≥70 years, female, CNS involvement, lung cancer, higher initial severity grade, and lack of systemic autoimmunity. By multivariate analysis, only age remained independently associated with poor outcome (p = 0.01). Four of 5 patients with preexistent neurologic autoimmunity experienced irreversible worsening after ICI. CONCLUSIONS Neural-specific autoantibodies are not uncommon in patients with ICI-related CNS neurologic autoimmunity. Outcomes mostly depend on the pre-ICI treatment characteristics and clinical phenotype.
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Affiliation(s)
- Elia Sechi
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Svetomir N Markovic
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Andrew McKeon
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Divyanshu Dubey
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Teerin Liewluck
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Vanda A Lennon
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - A Sebastian Lopez-Chiriboga
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Christopher J Klein
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Michelle Mauermann
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Sean J Pittock
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Eoin P Flanagan
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL
| | - Anastasia Zekeridou
- From the Departments of Neurology (E.S., A.M., D.D., T.L., V.A.L., C.J.K., M.M., S.J.P., E.P.F., A.Z.), Oncology (S.N.M.), Laboratory Medicine and Pathology (A.M., D.D., V.A.L., S.J.P., E.P.F., A.Z.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; and Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL.
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Liu Y, Jiang L. Tofacitinib for treatment in immune-mediated myocarditis: The first reported cases. J Oncol Pharm Pract 2020; 27:1078155220947141. [PMID: 32781887 DOI: 10.1177/1078155220947141] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICI) has demonstrated significant clinical benefit in advanced cancer. Despite favorable benefits, the use of ICI is accompanied by various side effects, which are inflammatory side effects potentially affecting any organ. Among which myocarditis is the most severe and has a relatively high mortality. However, there is no effective treatments, and many patients respond poorly to glucocorticoids and immunosuppressants. Therefore, it is urgent to explore effective treatments. CASES REPORT Here we describe two patients with metastatic cancer who developed immune-mediated myocarditis after receiving anti-programmed cell death protein (PD)-1 antibody. The main clinical manifestations are dyspnea. All patients had an elevation of cardiac enzyme, a variety of atypical electrocardiographic (ECG) abnormalities and preserved left ventricular ejection fraction (LVEF). All our patients underwent cardiac MRI (CMRI) and suggested typical features of myocarditis, including myocardial oedema and delayed enhancement.Management and outcome: All patients were treated promptly with glucocorticoids, followed by other immunosuppressive treatments include plasma exchange and intravenous immunoglobulin (IVIG). However, no significant improvement was observed and we then administered tofacitinib 5 mg twice daily to treat the refractory myocarditis and the elevated levels of pro-inflammatory cytokines. All patients recovered and were discharged. No major adverse reaction was reported during tofacitinib therapy. DISCUSSION To our knowledge, this is the first report in the world of patients with ICI-associated myocarditis treated with oral tofacitinib. Our results can at least provide a new option for clinical treatment of refractory myocarditis or other immune-related adverse events.
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Affiliation(s)
- Yun Liu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, PR China
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Diagnosis and Treatment of Rheumatic Adverse Events Related to Immune Checkpoint Inhibitors. J Immunol Res 2020; 2020:2640273. [PMID: 32832568 PMCID: PMC7424376 DOI: 10.1155/2020/2640273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/14/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have completely changed the treatment of cancer, and they also can cause multiple organ immune-related adverse reactions (irAEs). Among them, rheumatic irAE is less common, mainly including inflammatory arthritis, rheumatic myalgia/giant cell arteritis, inflammatory myopathy, and Sjogren's syndrome. For oncologists, rheumatism is a relatively new field, and early diagnosis and treatment is very important, and we need to work closely with experienced rheumatologists. In this review, we focused on the incidence, clinical characteristics, and treatment strategies of rheumatic irAE.
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159
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Neurologic Manifestations of Systemic Disease: Peripheral Nervous System. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00631-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Zhong H, Zhou J, Xu D, Zeng X. Rheumatic immune-related adverse events induced by immune checkpoint inhibitors. Asia Pac J Clin Oncol 2020; 17:178-185. [PMID: 32717098 PMCID: PMC8246553 DOI: 10.1111/ajco.13346] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/26/2020] [Indexed: 12/11/2022]
Abstract
Immune checkpoint inhibitors (ICIs) block the major inhibitory pathways in T cells, resulting in an augmented antitumor response. Immune‐related adverse events (irAEs) are a new class of side effects caused by ICIs and tend to be more prevalent in patients with preexisting autoantibodies and autoimmune diseases. The rheumatic subset of irAEs mainly includes arthralgia, arthritis, myalgia, myositis, vasculitis, sicca syndrome, scleroderma and systemic lupus erythematosus. The most common classification system for AEs, the Common Terminology Criteria for Adverse Events, is of limited use for irAEs, especially rheumatic irAEs. Therapy with glucocorticoid and temporary or permanent discontinuation of ICIs are the cornerstones of irAE treatment, and can be complemented with immunosuppressants (e.g., methotrexate), biologic agents (e.g., tumor necrosis factor inhibitors and interleukin‐6 receptor antagonists), intravenous immunoglobin and plasma exchange. Thus, the evaluation and treatment of rheumatic irAEs require multidisciplinary cooperation among physicians. Here, we review the most prevalent ICI‐associated rheumatic irAEs.
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Affiliation(s)
- Hui Zhong
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Jiaxin Zhou
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
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Lorenzo CJ, Fitzpatrick H, Campdesuner V, George J, Lattanzio N. Pembrolizumab-Induced Ocular Myasthenic Crisis. Cureus 2020; 12:e9192. [PMID: 32685327 PMCID: PMC7366038 DOI: 10.7759/cureus.9192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Pembrolizumab, one of many novel immune checkpoint inhibitors (ICPi), is a monoclonal antibody that enhances immunity against cancer cells. Extensive escalation in immune activity predisposes to unsought immune-related adverse events. Due to progressive mesothelioma, a 67-year-old man was referred to the research unit and enrolled in a clinical trial with a cluster of differentiation (CD) 27 chemotherapeutic agent. He began crossover treatment and received just two doses of pembrolizumab, 33 and 16 days prior to admission. He subsequently presented to the emergency department with three days of acute onset severe diplopia and a drooping left eye. Acetylcholine receptor (AChR) antibodies returned positive at 13.9 nmol/L, and a diagnosis of ocular myasthenia gravis (OMG) was made. During his hospitalization, the patient was managed with methylprednisolone 80 mg intravenously daily, with conversion to prednisone 60 mg by mouth daily at time of discharge. Neuro-ophthalmology consultation was sought in the outpatient setting, and the patient was started on pyridostigmine. He was readmitted two weeks later with symptoms of progressive diffuse weakness, unsteady gait, and dysphagia, all in the setting of persistent diplopia. Intravenous immunoglobulin (IVIG) was promptly initiated, in addition to the pyridostigmine previously initiated in the outpatient setting. Unfortunately, after three IVIG treatments, the patient had experienced little improvement in his symptoms, and therefore elected hospice care. Although ICPis have revolutionized the management of a multitude of malignancies, recognition of immune-related adverse events is of critical importance.
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Affiliation(s)
- Christian J Lorenzo
- Internal Medicine, Sarasota Memorial Hospital, Florida State University College of Medicine, Sarasota, USA
| | | | - Victoria Campdesuner
- Internal Medicine, Sarasota Memorial Hospital, Florida State University College of Medicine, Sarasota, USA
| | - Justin George
- Internal Medicine, Sarasota Memorial Hospital, Florida State University College of Medicine, Sarasota, USA
| | - Natalia Lattanzio
- Internal Medicine, Sarasota Memorial Hospital, Florida State University College of Medicine, Sarasota, USA
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Immune Checkpoint Inhibition-Does It Cause Rheumatic Diseases? Mechanisms of Cancer-Associated Loss of Tolerance and Pathogenesis of Autoimmunity. Rheum Dis Clin North Am 2020; 46:587-603. [PMID: 32631606 DOI: 10.1016/j.rdc.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mechanisms of immune checkpoints and their role in autoimmunity are discussed in the context of immune checkpoint inhibitor (ICI) therapy for cancer. The updated clinical spectrum of immune-related adverse events (irAEs), with an in-depth discussion of rheumatic irAEs, is presented. The relationship between ICI-induced loss of self-tolerance in cancer and the implications for understanding of irAEs, rheumatic irAEs in particular, is overviewed.
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The Terrible Triad of Checkpoint Inhibition: A Case Report of Myasthenia Gravis, Myocarditis, and Myositis Induced by Cemiplimab in a Patient with Metastatic Cutaneous Squamous Cell Carcinoma. Case Reports Immunol 2020; 2020:5126717. [PMID: 32695533 PMCID: PMC7355354 DOI: 10.1155/2020/5126717] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 12/21/2022] Open
Abstract
Background We report a case of a patient with squamous cell carcinoma (SCC) who developed myasthenia gravis (MG), myositis, and myocarditis after receiving cemiplimab, an anti-PD-1 immune checkpoint inhibitor (ICI). Case Presentation. An 86-year-old man with metastatic periocular SCC presented with decreased vision in the left eye, severe fatigue, and lower back and bilateral hip pain 3 weeks after receiving cemiplimab. Within hours, he developed dysphonia, pharyngeal secretions, and dysphagia, necessitating intubation. Endomyocardial biopsy revealed active lymphocyte-mediated necrosis consistent with ICI-induced myocarditis. Anti-striated muscle and anti-acetylcholine receptor antibodies were elevated, consistent with myositis and myasthenia gravis. Despite plasma exchange therapy, steroids, and intravenous immunoglobulin, he died from cardiac arrest. Conclusions The presence of myasthenia gravis, myocarditis, or myositis should prompt evaluation for all three toxicities as they may represent an overlap syndrome. The severity of these immunotoxicities highlights the need for clinicians to suspect multiple simultaneous adverse effects of ICIs.
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Bennett KM, Fernandes PM. Novel treatments for progressive multifocal leukoencephalopathy. Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32730143 DOI: 10.12968/hmed.2020.0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Progressive multifocal leukoencephalopathy is a rare demyelinating disorder of the CNS, caused by John Cunningham virus, that occurs in those with impaired immune systems. Existing treatment options are ineffective or unproven. This article reviews research into novel therapies: immune checkpoint-blocking antibodies (nivolumab and pembrolizumab), allogenic BK virus-specific T cell treatment and filgrastim. Results for these therapies in small clinical trials are promising, but further research is required to assess efficacy fully.
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Affiliation(s)
- Karina M Bennett
- Department of Neurology, NHS Lothian, Western General Hospital, Edinburgh, UK
| | - Peter M Fernandes
- Department of Neurology, NHS Lothian, Western General Hospital, Edinburgh, UK.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Vogrig A, Muñiz-Castrillo S, Joubert B, Picard G, Rogemond V, Marchal C, Chiappa AM, Chanson E, Skowron F, Leblanc A, Ducray F, Honnorat J. Central nervous system complications associated with immune checkpoint inhibitors. J Neurol Neurosurg Psychiatry 2020; 91:772-778. [PMID: 32312871 DOI: 10.1136/jnnp-2020-323055] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/24/2020] [Accepted: 04/08/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe the spectrum and outcome of central nervous system complications associated with immune checkpoint inhibitors (CNS-ICI). METHODS Patients with CNS-ICI were identified and their characteristics compared with ICI-related peripheral neuropathy (PN-ICI). RESULTS We identified 19 patients with CNS-ICI. The patients were receiving nivolumab (n=8), pembrolizumab (n=6), a combination of ipilimumab-nivolumab (n=3), ipilimumab-durvalumab (n=1), or atezolizumab (n=1). Underlying malignancies included non-small-cell lung cancer (n=8), melanoma (n=3), and other less common tumours (n=8). Neurological phenotypes were limbic encephalitis (n=8), meningoencephalitis (n=4) and cerebellitis (n=4). Two patients developed isolated confusion and one parkinsonism. Associated autoantibodies included onconeural (Ma2, n=7; Hu, n=1), astrocytic (glial fibrillar acidic protein, n=2) and neuronal surface (contactin-associated protein-like 2, n=1) specificities. ICIs were withheld and corticosteroid treatment was given in all cases. Five patients received intravenous immunoglobulin, two rituximab, one plasmapheresis and one infliximab. Overall, six patients died. Readministration of ICI was attempted in three patients, without further relapses. Non-small-cell lung cancer was significantly more frequent in patients with CNS-ICI (p<0.01), while melanoma and ipilimumab treatment were more common in PN-ICI (p<0.01 and p=0.01). Conversely, CNS-ICI cases were more frequently antibody-positive than PN-ICI (p<0.01) and showed a strong trend towards poorer outcome (p=0.053). CONCLUSION Three main clinical phenotypes characterise CNS complications of ICIs, each with distinct immunological background, disease course and response to treatment. Other clinical manifestations (including parkinsonism and steroid-responsive confusion) are also possible. Underlying cancers, antibody prevalence and outcome appear different from those of patients with PN-ICI.
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Affiliation(s)
- Alberto Vogrig
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Sergio Muñiz-Castrillo
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Bastien Joubert
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Geraldine Picard
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Veronique Rogemond
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Cécile Marchal
- Service de Neurologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | - Eve Chanson
- Service de Neurologie, Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France
| | | | - Amelie Leblanc
- Service de Neurologie, CHRU Cavale-Blanche, Brest, France
| | - François Ducray
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Jerome Honnorat
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France .,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
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167
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Vogrig A, Muñiz-Castrillo S, Desestret V, Joubert B, Honnorat J. Pathophysiology of paraneoplastic and autoimmune encephalitis: genes, infections, and checkpoint inhibitors. Ther Adv Neurol Disord 2020; 13:1756286420932797. [PMID: 32636932 PMCID: PMC7318829 DOI: 10.1177/1756286420932797] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/17/2020] [Indexed: 12/14/2022] Open
Abstract
Paraneoplastic neurological syndromes (PNSs) are rare complications of systemic cancers that can affect all parts of the central and/or peripheral nervous system. A body of experimental and clinical data has demonstrated that the pathogenesis of PNSs is immune-mediated. Nevertheless, the mechanisms leading to immune tolerance breakdown in these conditions remain to be elucidated. Despite their rarity, PNSs offer a unique perspective to understand the complex interplay between cancer immunity, effect of immune checkpoint inhibitors (ICIs), and mechanisms underlying the attack of neurons in antibody-mediated neurological disorders, with potentially relevant therapeutic implications. In particular, it is reported that ICI treatment can unleash PNSs and that the immunopathological features of PNS-related tumors are distinctive, showing prominent tumor-infiltrating lymphocytes and germinal center reactions. Intriguingly, similar pathological substrates have gained further attention as potential biomarkers of ICI-sensitivity and oncological prognosis. Moreover, the genetic analysis of PNS-associated tumors has revealed specific molecular signatures and mutations in genes encoding onconeural proteins, leading to the production of highly immunogenic neoantigens. Other than PNSs, autoimmune encephalitides (AEs) comprise a recently described group of disorders characterized by prominent neuropsychiatric symptoms, diverse antibody spectrum, and less tight association with cancer. Other triggering factors seem to be involved in AEs. Recent data have shed light on the importance of preceding infections (in particular, herpes simplex virus encephalitis) in inducing neurological autoimmune disorders in susceptible individuals (those with a selective deficiency in the innate immune system). In addition, in some AEs (e.g. LGI1-antibody encephalitis) an association with specific host-related factors [e.g., human leukocyte antigen (HLA)] was clearly demonstrated. We provide herein a comprehensive review of the most recent findings in the field of PNSs and AEs, with particular focus on their triggering factors and immunopathogenesis.
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Affiliation(s)
- Alberto Vogrig
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Sergio Muñiz-Castrillo
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Virginie Desestret
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Bastien Joubert
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Jérôme Honnorat
- Centre de Référence National pour les Syndromes Neurologiques Paranéoplasiques, Hôpital Neurologique, 59 Boulevard Pinel, Bron Cedex, 69677, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
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168
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Kimura T, Fukushima S, Okada E, Kuriyama H, Kanemaru H, Kadohisa-Tsuruta M, Kubo Y, Nakahara S, Tokuzumi A, Kajihara I, Makino K, Miyashita A, Aoi J, Makino T, Tsukamoto H, Nishimura Y, Inozume T, Zhang R, Uemura Y, Senju S, Ihn H. Induced pluripotent stem cell-derived myeloid cells expressing OX40 ligand amplify antigen-specific T cells in advanced melanoma. Pigment Cell Melanoma Res 2020; 33:744-755. [PMID: 32353897 DOI: 10.1111/pcmr.12887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 11/27/2022]
Abstract
Immune checkpoint inhibitors improved the survival rate of patients with unresectable melanoma. However, some patients do not respond, and variable immune-related adverse events have been reported. Therefore, more effective and antigen-specific immune therapies are urgently needed. We previously reported the efficacy of an immune cell therapy with immortalized myeloid cells derived from induced pluripotent stem cells (iPS-ML). In this study, we generated OX40L-overexpressing iPS-ML (iPS-ML-Zsgreen-OX40L) and investigated their characteristics and in vivo efficacy against mouse melanoma. We found that iPS-ML-Zsgreen-OX40L suppressed the progression of B16-BL6 melanoma, and prolonged survival of mice with ovalbumin (OVA)-expressing B16 melanoma (MO4). The number of antigen-specific CD8+ T cells was higher in spleen cells treated with OVA peptide-pulsed iPS-ML-Zsgreen-OX40L than in those without OX40L. The OVA peptide-pulsed iPS-ML-Zsgreen-OX40L significantly increased the number of tumor-infiltrating T lymphocytes (TILs) in MO4 tumor. Flow cytometry showed decreased regulatory T cells but increased effector and effector memory T cells among the TILs. Although we plan to use allogeneic iPS-ML in the clinical applications, iPS-ML showed the tumorgenicity in the syngeneic mice model. Incorporating the suicide gene is necessary to ensure the safety in the future study. Collectively, these results indicate that iPS-ML-Zsgreen-OX40L therapy might be a new method for antigen-specific cancer immunotherapy.
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Affiliation(s)
- Toshihiro Kimura
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Fukushima
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Etsuko Okada
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Haruka Kuriyama
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisashi Kanemaru
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Mina Kadohisa-Tsuruta
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yosuke Kubo
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Nakahara
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Aki Tokuzumi
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Ikko Kajihara
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Katsunari Makino
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Azusa Miyashita
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Jun Aoi
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Takamitsu Makino
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirotake Tsukamoto
- Department of Immunology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuharu Nishimura
- Department of Immunogenetics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Nishimura Project Laboratory, Institute of Resource Development and Analysis, Kumamoto University, Kumamoto, Japan
| | - Takashi Inozume
- Department of Dermatology, University of Yamanashi, Yamanashi, Japan
| | - Rong Zhang
- Division of Cancer Immunotherapy, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center (NCC), Chiba, Japan
| | - Yasushi Uemura
- Division of Cancer Immunotherapy, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center (NCC), Chiba, Japan
| | - Satoru Senju
- Department of Immunogenetics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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169
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Fatal autoimmune storm after a single cycle of anti-PD-1 therapy: A case of lethal toxicity but pathological complete response in metastatic lung adenocarcinoma. Hematol Oncol Stem Cell Ther 2020; 15:63-67. [PMID: 32442551 DOI: 10.1016/j.hemonc.2020.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 04/05/2020] [Indexed: 11/23/2022] Open
Abstract
As immunotherapy agents are incorporated into the routine oncological practice, the number of patients at the risk of immune-related adverse events has increased dramatically. However, the prompt identification and effective management of severe autoimmune complications remain a challenge. We report the case of a patient with metastatic lung adenocarcinoma who experienced a fatal autoimmune storm 3 weeks after the first dose of anti-programmed death receptor-1 (PD-1) agent pembrolizumab, which included thyroiditis, hepatitis, myositis, myocarditis, pneumonitis, and myasthenia gravis. Aggressive autoimmunity was supported by extensive T-cell and macrophage tissue infiltrates and autoantibody positivity. Remarkably, no residual tumor was found at autopsy. This case illustrates the potential harm caused by immunotherapy and our limited knowledge on its prevention, treatment, and association to antitumor efficacy.
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170
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Rheumatic Manifestations in Patients Treated with Immune Checkpoint Inhibitors. Int J Mol Sci 2020; 21:ijms21093389. [PMID: 32403289 PMCID: PMC7247001 DOI: 10.3390/ijms21093389] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that activate the immune system, aiming at enhancing antitumor immunity. Their clinical efficacy is well-documented, but the side effects associated with their use are still under investigation. These drugs cause several immune-related adverse events (ir-AEs), some of which stand within the field of rheumatology. Herein, we present a literature review performed in an effort to evaluate all publicly available clinical data regarding rheumatic manifestations associated with ICIs. The most common musculoskeletal ir-AEs are inflammatory arthritis, polymyalgia rheumatica and myositis. Non-musculoskeletal rheumatic manifestations are less frequent, with the most prominent being sicca, vasculitides and sarcoidosis. Cases of systemic lupus erythematosus or scleroderma are extremely rare. The majority of musculoskeletal ir-AEs are of mild/moderate severity and can be managed with steroids with no need for ICI discontinuation. In severe cases, more intense immunosuppressive therapy and permanent ICI discontinuation may be employed. Oncologists should periodically screen patients receiving ICIs for new-onset inflammatory musculoskeletal complaints and seek a rheumatology consultation in cases of persisting symptoms.
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171
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Parthymos I, Liamis G, Dounousi E, Pentheroudakis G, Mauri D, Zarkavelis G, Florentin M. Metabolic consequences of immune checkpoint inhibitors: A new challenge in clinical practice. Crit Rev Oncol Hematol 2020; 151:102979. [PMID: 32480349 DOI: 10.1016/j.critrevonc.2020.102979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 02/29/2020] [Accepted: 05/03/2020] [Indexed: 12/13/2022] Open
Abstract
Treatment of oncologic patients has progressed greatly the last few years with the development of immune checkpoint inhibitors (ICPIs). These drugs are associated with the immune system and, thus, may cause side effects of immune origin, the so called immune related adverse events (irAEs). Immune related AEs may actually affect all organs and systems and frequently resemble clinical entities commonly encountered in clinical practice. As ICPIs have improved both quality of life and life expectancy, clinicians of various specialties may need to deal with irAEs in their everyday practice. Therefore, they should be able to recognize them timely and treat them accordingly. Herein, we review the pathophysiology, clinical manifestations and treatment of irAEs.
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Affiliation(s)
- Ioannis Parthymos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Evangelia Dounousi
- Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Pentheroudakis
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - Davide Mauri
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - George Zarkavelis
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - Matilda Florentin
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece.
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172
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Ramos-Casals M, Brahmer JR, Callahan MK, Flores-Chávez A, Keegan N, Khamashta MA, Lambotte O, Mariette X, Prat A, Suárez-Almazor ME. Immune-related adverse events of checkpoint inhibitors. Nat Rev Dis Primers 2020; 6:38. [PMID: 32382051 PMCID: PMC9728094 DOI: 10.1038/s41572-020-0160-6] [Citation(s) in RCA: 719] [Impact Index Per Article: 179.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 02/06/2023]
Abstract
Cancer immunotherapies have changed the landscape of cancer treatment during the past few decades. Among them, immune checkpoint inhibitors, which target PD-1, PD-L1 and CTLA-4, are increasingly used for certain cancers; however, this increased use has resulted in increased reports of immune-related adverse events (irAEs). These irAEs are unique and are different to those of traditional cancer therapies, and typically have a delayed onset and prolonged duration. IrAEs can involve any organ or system. These effects are frequently low grade and are treatable and reversible; however, some adverse effects can be severe and lead to permanent disorders. Management is primarily based on corticosteroids and other immunomodulatory agents, which should be prescribed carefully to reduce the potential of short-term and long-term complications. Thoughtful management of irAEs is important in optimizing quality of life and long-term outcomes.
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Affiliation(s)
- Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Barcelona, Spain. .,Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain. .,Department of Medicine, University of Barcelona, Hospital Clínic, Barcelona, Spain.
| | - Julie R. Brahmer
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Margaret K. Callahan
- Melanoma and Immunotherapeutics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA,Parker Institute for Cancer Immunotherapy, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Niamh Keegan
- Melanoma and Immunotherapeutics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Munther A. Khamashta
- Lupus Clinic, Rheumatology Department, Dubai Hospital, Dubai, United Arab Emirates
| | - Olivier Lambotte
- APHP Médecine Interne/Immunologie Clinique, Hôpital Bicêtre, Paris, France,Université Paris-Saclay – INSERM U1184 - CEA, Immunology of Viral Infections and Autoimmune Diseases, IDMIT Department, IBFJ, Fontenay-aux-Roses and Le Kremlin-Bicêtre, France
| | - Xavier Mariette
- Université Paris-Saclay, INSERM, CEA, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ; AP-HP.Université Paris-Saclay, Hôpital Bicêtre, Rheumatology Department, Le Kremlin Bicêtre, France
| | - Aleix Prat
- Translational Genomic and Targeted Therapeutics in Solid Tumors, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Department of Medical Oncology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Maria E. Suárez-Almazor
- Section of Rheumatology/Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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173
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Immune checkpoint inhibitors (ICIs)-related ocular myositis. Neuromuscul Disord 2020; 30:420-423. [DOI: 10.1016/j.nmd.2020.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 01/15/2020] [Accepted: 02/18/2020] [Indexed: 11/19/2022]
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174
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Zhang S, Wang L, Li M, Zhang F, Zeng X. The PD-1/PD-L pathway in rheumatic diseases. J Formos Med Assoc 2020; 120:48-59. [PMID: 32334916 DOI: 10.1016/j.jfma.2020.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/PURPOSE Autoimmune diseases are diseases in which the body produces an abnormal immune response to self-antigens and damages its own tissues. Programmed death-1 (PD-1) and its ligands (PD-Ls) have been discovered to be important negative regulators of the immune system, playing crucial roles in autoimmunity. METHODS We analyzed the existing scientific literature dealing with this issue. In this review, the PD-1/PD-L pathway in the genetic susceptibility to and pathogenesis of rheumatic diseases is discussed. The PD-1/PD-L pathway might be helpful for diagnosing, evaluating the disease activity of and treating rheumatic diseases. RESULTS PD-1/PD-L gene polymorphisms are associated with a genetic predisposition to rheumatic disorders, which can provide reference information for diagnosis and disease activity. The conclusion of the crucial role of the PD-1/PD-L pathway in the pathogenesis of rheumatic diseases is consistent, but the details remain controversial. In some animal models, manipulating the PD-1/PD-L pathway could decrease disease severity. PD-1/PD-Ls may enable us to develop new therapeutics for patients with rheumatic diseases in the future. CONCLUSION The PD-1/PD-L pathway plays crucial roles in rheumatic disease. More work is needed to provide a better mechanistic understanding of the PD-1/PD-L pathway and to facilitate the precise therapeutic manipulation of this pathway.
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Affiliation(s)
- Shuo Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Li Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Fengchun Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
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175
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Kostine M, Finckh A, Bingham CO, Visser K, Leipe J, Schulze-Koops H, Choy EH, Benesova K, Radstake TRDJ, Cope AP, Lambotte O, Gottenberg JE, Allenbach Y, Visser M, Rusthoven C, Thomasen L, Jamal S, Marabelle A, Larkin J, Haanen JBAG, Calabrese LH, Mariette X, Schaeverbeke T. EULAR points to consider for the diagnosis and management of rheumatic immune-related adverse events due to cancer immunotherapy with checkpoint inhibitors. Ann Rheum Dis 2020; 80:36-48. [PMID: 32327425 PMCID: PMC7788064 DOI: 10.1136/annrheumdis-2020-217139] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
Background Rheumatic and musculoskeletal immune-related adverse events (irAEs) are observed in about 10% of patients with cancer receiving checkpoint inhibitors (CPIs). Given the recent emergence of these events and the lack of guidance for rheumatologists addressing them, a European League Against Rheumatism task force was convened to harmonise expert opinion regarding their identification and management. Methods First, the group formulated research questions for a systematic literature review. Then, based on literature and using a consensus procedure, 4 overarching principles and 10 points to consider were developed. Results The overarching principles defined the role of rheumatologists in the management of irAEs, highlighting the shared decision-making process between patients, oncologists and rheumatologists. The points to consider inform rheumatologists on the wide spectrum of musculoskeletal irAEs, not fulfilling usual classification criteria of rheumatic diseases, and their differential diagnoses. Early referral and facilitated access to rheumatologist are recommended, to document the target organ inflammation. Regarding therapeutic, three treatment escalations were defined: (1) local/systemic glucocorticoids if symptoms are not controlled by symptomatic treatment, then tapered to the lowest efficient dose, (2) conventional synthetic disease-modifying antirheumatic drugs, in case of inadequate response to glucocorticoids or for steroid sparing and (3) biological disease-modifying antirheumatic drugs, for severe or refractory irAEs. A warning has been made on severe myositis, a life-threatening situation, requiring high dose of glucocorticoids and close monitoring. For patients with pre-existing rheumatic disease, baseline immunosuppressive regimen should be kept at the lowest efficient dose before starting immunotherapies. Conclusion These statements provide guidance on diagnosis and management of rheumatic irAEs and aim to support future international collaborations.
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Affiliation(s)
- Marie Kostine
- Rheumatology, University Hospital of Bordeaux, Bordeaux, France
| | - Axel Finckh
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | | | - Karen Visser
- Rheumatology, Haga Hospital, Den Haag, The Netherlands
| | - Jan Leipe
- Department of Medicine V, Division of Rheumatology, University Hospital Centre, Mannheim, Germany.,Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Hendrik Schulze-Koops
- Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Ernest H Choy
- Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
| | | | | | - Andrew P Cope
- Academic Department of Rheumatology, King's College London, London, UK
| | - Olivier Lambotte
- Internal Medicine and Clinical Immunology, Hopital Bicetre, Le Kremlin-Bicetre, France
| | | | - Yves Allenbach
- Internal Medicine and Clinical Immunology, Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France
| | - Marianne Visser
- EULAR PARE Patient Research Partners, Amsterdam, The Netherlands
| | - Cindy Rusthoven
- EULAR PARE Patient Research Partners, Amsterdam, The Netherlands
| | | | - Shahin Jamal
- Rheumatology, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - James Larkin
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - John B A G Haanen
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | | | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, Le Kremlin Bicêtre, France.,3Université Paris-Sud, Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
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Psimaras D, Velasco R, Birzu C, Tamburin S, Lustberg M, Bruna J, Argyriou AA. Immune checkpoint inhibitors-induced neuromuscular toxicity: From pathogenesis to treatment. J Peripher Nerv Syst 2020; 24 Suppl 2:S74-S85. [PMID: 31393660 DOI: 10.1111/jns.12339] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/15/2019] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are increasingly used and are becoming the standard of care in the treatment of various tumor types. Despite the favorable results in terms of oncological outcomes, these treatments have been associated with a variety of immune-related adverse events (irAEs). Neurological irAEs are rare but potentially severe. Neuromuscular disorders represent the most common neurological irAEs following anti-PD-1, anti-PD-L1, and anti-CTLA-4 treatment, and include myositis, myasthenia gravis, and demyelinating polyradiculoneuropathy. Instrumental findings may differ from typical neuromuscular disorders occurring outside ICIs treatment. Despite initial severity, neurological irAEs often respond to immune-modulating therapies. Prompt irAEs diagnosis, ICIs discontinuation, and early treatment with corticosteroids, together with patient education and a multi-disciplinary approach, are important for optimizing clinical outcomes. Intravenous immunoglobulin, plasma exchange, and other immune-modulating treatments should be considered in more severe cases. Consideration of re-challenging with the same immunotherapy drug may be given in some cases, based on clinical picture and initial severity of irAEs.
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Affiliation(s)
- Dimitri Psimaras
- AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, Service de Neurologie Mazarin, Paris, France.,Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France.,OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpetrière-Charles Foix et Hôpital Percy, Paris, France
| | - Roser Velasco
- Unit of Neuro-Oncology, Hospital Universitari de Bellvitge-Institut Català D'Oncologia L'Hospitalet, IDIBELL, Barcelona, Spain.,Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Barcelona, Spain
| | - Cristina Birzu
- AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, Service de Neurologie Mazarin, Paris, France.,Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France.,OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpetrière-Charles Foix et Hôpital Percy, Paris, France
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maryam Lustberg
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer, Columbus, Ohio
| | - Jordi Bruna
- Unit of Neuro-Oncology, Hospital Universitari de Bellvitge-Institut Català D'Oncologia L'Hospitalet, IDIBELL, Barcelona, Spain.,Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Barcelona, Spain
| | - Andreas A Argyriou
- Department of Neurology, "Saint Andrew's" State General Hospital of Patras, Patras, Greece
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177
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Guidon AC. Lambert-Eaton Myasthenic Syndrome, Botulism, and Immune Checkpoint Inhibitor-Related Myasthenia Gravis. Continuum (Minneap Minn) 2020; 25:1785-1806. [PMID: 31794471 DOI: 10.1212/con.0000000000000807] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW This article reviews the pathophysiology, epidemiology, clinical presentation, diagnosis, and treatment of Lambert-Eaton myasthenic syndrome (LEMS) and of botulism, and immune-related myasthenia gravis (MG) occurring in the context of immune checkpoint inhibitor therapy for cancer. RECENT FINDINGS The suspicion that LEMS is rare but also likely underdiagnosed is supported by recent epidemiologic data. A validated, LEMS-specific scale now exists to assess and monitor disease, and symptomatic and immunomodulatory treatments are available. As presynaptic disorders of neuromuscular transmission, LEMS and botulism share electrodiagnostic abnormalities but have important distinguishing features. Knowledge of the clinical features of botulism is needed, particularly with continued cases of infant botulism, the opioid epidemic increasing the incidence of wound botulism, and medical use of botulinum toxin, which may cause iatrogenic botulism. Foodborne botulism remains rare. Prompt recognition of botulism and administration of antitoxin can improve outcomes. MG may be exacerbated or may present de novo in the context of immune activation from immune checkpoint inhibitor therapies for cancer. Immune-related MG commonly overlaps with myositis and myocarditis. Corticosteroids typically result in improvement. However, immune-related MG can be more fulminant than its idiopathic counterpart and may cause permanent disability or death. SUMMARY The diagnosis of LEMS, botulism, or immune-related MG can generally be made from the patient's history, supplemented with directed questions, a physical examination designed to demonstrate abnormalities, and laboratory and electrodiagnostic testing. Early diagnosis and carefully selected treatment not only improve outcomes of the neuromuscular disease but can affect the prognosis of underlying malignancy, when present.
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178
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Abstract
PURPOSE OF REVIEW This article reviews the pathogenesis, clinical features, and management of toxic myopathy related to common medications, critical illness, and illicit substances. RECENT FINDINGS Muscle symptoms are common among statin users and are usually reversible after discontinuation of the statin; rarely, however, statins trigger an immune-mediated necrotizing myopathy that persists and requires immunomodulatory therapy. Autoantibodies targeting 3-hydroxy-3-methylglutaryl coenzyme A reductase can distinguish the toxic and immune-mediated forms. Immune checkpoint inhibitors, increasingly used in the treatment of advanced cancer, have recently been associated with the development of inflammatory myositis. A reversible mitochondrial myopathy has long been associated with zidovudine, but recent reports elucidate the risk of myopathy with newer antivirals, such as telbivudine and raltegravir. SUMMARY The medications most commonly associated with myopathy include statins, amiodarone, chloroquine, hydroxychloroquine, colchicine, certain antivirals, and corticosteroids, and myopathy can occur with chronic alcoholism. Certain clinical, electrodiagnostic, and histologic features can aid in early recognition. Stopping the use of the offending agent reverses symptoms in most cases, but specific and timely treatment may be required in cases related to agents that trigger immune-mediated muscle injury.
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179
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Szuchan C, Elson L, Alley E, Leung K, Camargo AL, Elimimian E, Nahleh Z, Sadler D. Checkpoint inhibitor-induced myocarditis and myasthenia gravis in a recurrent/metastatic thymic carcinoma patient: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-8. [PMID: 32617460 PMCID: PMC7319805 DOI: 10.1093/ehjcr/ytaa051] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/01/2019] [Accepted: 02/12/2020] [Indexed: 12/12/2022]
Abstract
Background Pembrolizumab, an immune checkpoint inhibitor (ICI), is an IgG4 antibody that blocks interaction between programmed cell death protein 1 and programmed death-ligand 1. Myocarditis, an immune-related adverse event, has been reported in thymic epithelial tumours. Pembrolizumab has also been associated with development/exacerbation of myasthenia gravis (MG). Case summary A 70-year-old woman with metastatic thymic cancer presented to the hospital with shortness of breath, 21 days after initiation of pembrolizumab. She was diagnosed with ICI-related myocarditis and was subsequently intubated due to respiratory failure. A dual-chamber pacemaker was placed due to complete heart block with asystole. Her troponin levels were elevated, an electrocardiogram was suspicious for myocardial infarction, but coronary angiogram revealed normal coronary arteries and endomyocardial biopsy confirmed the presence of myocarditis. Treatment was started with high-dose intravenous methylprednisolone and cardiovascular status improved. However, the patient was unable to be weaned from mechanical ventilation and tested positive for acetylcholine receptor binding/blocking antibodies due to de novo MG. After 50 days of hospitalization, she was discharged home in stable condition. A computed tomography scan was performed 6 weeks after pembrolizumab; results showed significant decrease/resolution of all measurable sites of metastatic disease in the lungs. Discussion This is the first reported case of a patient developing single-agent pembrolizumab-induced myocarditis concomitant with new-onset MG after treatment for advanced thymic malignancy. Additional studies are needed to explore the association between myocarditis, MG, and ICI therapy.
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Affiliation(s)
- Charles Szuchan
- Maroone Cancer Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Leah Elson
- Maroone Cancer Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Evan Alley
- Maroone Cancer Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Kevin Leung
- Heart and Vascular Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Antonio Lewis Camargo
- Heart and Vascular Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Elizabeth Elimimian
- Maroone Cancer Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Zeina Nahleh
- Maroone Cancer Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Diego Sadler
- Heart and Vascular Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
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180
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Steven NM, Fisher BA. Management of rheumatic complications of immune checkpoint inhibitor therapy - an oncological perspective. Rheumatology (Oxford) 2020; 58:vii29-vii39. [PMID: 31816079 PMCID: PMC6900910 DOI: 10.1093/rheumatology/kez536] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (CPIs) are an effective treatment for many cancers but cause diverse immune-related adverse events (IrAEs). Rheumatological IrAEs include arthralgia, arthritis, tenosynovitis, myositis, polymyalgia rheumatica and sicca syndrome. CPI use can unmask RA as well as causing flares of prior autoimmune or connective tissue disease. Oncologists categorize and grade IrAEs using the Common Terminology Criteria for Adverse Events and manage them according to international guidelines. However, rheumatological events are unfamiliar territory: oncologists need to work with rheumatologists to elicit and assess symptoms, signs, results of imaging and autoantibody testing and to determine the use of steroids and DMARDs. Myositis may overlap with myasthenic crisis and myocarditis and can be life-threatening. Treatment should be offered on balance of risk and benefit, including whether to continue CPI treatment and recognizing the uncertainty over whether glucocorticoids and DMARDs might compromise cancer control.
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Affiliation(s)
- Neil M Steven
- Institute of Immunology and Immunotherapy, Birmingham, UK.,Cancer Centre, University Hospital Birmingham, Birmingham, UK
| | - Benjamin A Fisher
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,National Institute of Health Research Birmingham Biomedical Research Centre and Department of Rheumatology, University Hospital Birmingham, Birmingham, UK
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181
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Kostine M, Truchetet ME, Schaeverbeke T. Clinical characteristics of rheumatic syndromes associated with checkpoint inhibitors therapy. Rheumatology (Oxford) 2020; 58:vii68-vii74. [PMID: 31816082 PMCID: PMC6900916 DOI: 10.1093/rheumatology/kez295] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/31/2019] [Indexed: 12/21/2022] Open
Abstract
Compared with conventional cancer therapies, the spectrum of toxicities observed with checkpoint inhibitors is unique and can affect any organ system. Arthralgia and myalgia were by far the most commonly reported rheumatic immune-related adverse events in clinical trials, and there is now a growing number of case series and reports describing clinical features of de novo rheumatic immune-related adverse events, which will be the focus of this review. Some patients develop genuine classic rheumatic and musculoskeletal diseases, but a number of rheumatic immune-related adverse events mimic rheumatic and musculoskeletal diseases with atypical features, mainly polymyalgia rheumatica, rheumatoid arthritis and myositis, as well as several systemic conditions, including sicca syndrome, vasculitis, sarcoidosis, systemic sclerosis and lupus.
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Affiliation(s)
- Marie Kostine
- Department of Rheumatology, Bordeaux University Hospital, Bordeaux, France
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182
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Myositis as a neuromuscular complication of immune checkpoint inhibitors. Acta Neurol Belg 2020; 120:355-364. [PMID: 31993961 DOI: 10.1007/s13760-020-01282-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/15/2020] [Indexed: 12/11/2022]
Abstract
Immune checkpoint inhibitors (ICI) induce improved clinical outcomes associated with numerous cancers, but immune-related adverse events can occur, including neuromuscular complications. We searched for all muscle biopsies from the patient data system of University Hospitals Leuven (UZ Leuven) from January 2014 to July 2018 (n = 686) and collected clinical data of patients with a biopsy-proven ICI-related myositis and expanded the pathological examinations. We identified three cases of ICI-related myositis in patients with malignant melanoma. The clinical phenotype ranged from mild to life threatening. Two patients had a myositis-myasthenia gravis overlap syndrome and one had a co-occurring myocarditis. Pathological examination showed a necrotizing and/or inflammatory myopathy with CD4 + and CD8 + T cells and CD68 + macrophages. IgG staining was positive in all cases. PD-1 and PD-L1 reactions were negative for inhibitors of the PD-1/PD-L1 pathway (nivolumab, atezolizumab) and positive for CTLA-4 inhibitors (ipilimumab). With increasing usage of ICI, clinicians must be aware of rare but potentially serious adverse events such as myositis. Early detection by inquiring about complaints and clinical signs of weakness and monitoring the creatine phosphokinase level in serum are recommended. Our histological findings are in line with other reports. The IgG positivity suggests a local role of the ICI in the pathophysiology of the myositis. Further research must be performed to identify patients at risk and to optimize treatment of the complications.
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183
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Haugh AM, Probasco JC, Johnson DB. Neurologic complications of immune checkpoint inhibitors. Expert Opin Drug Saf 2020; 19:479-488. [PMID: 32126176 PMCID: PMC7192781 DOI: 10.1080/14740338.2020.1738382] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/02/2020] [Indexed: 01/02/2023]
Abstract
Introduction: Immune checkpoint inhibitors (ICI) are associated with a wide spectrum of neurologic immune-related adverse events (irAEs) including meningo-encephalitis, myasthenia gravis and various neuropathies. Although relatively rare, they often present significant diagnostic complexity and may be under-recognized. Permanent neurologic deficits and/or fatality have been described but improvement is noted in most cases with ICI discontinuation and immunosuppressive therapy.Areas covered: This review highlights the most frequently reported ICI-associated neurologic toxicities with a particular focus on those that may be more severe and/or fatal. Data from case series and pharmacovigilance studies is leveraged to provide an overview of associated clinical features, expected outcomes and appropriate management. Various immunobiologic triggers have been proposed to explain why certain patients might develop neurologic irAEs and are also briefly discussed.Expert opinion: All providers who care for patients with cancer should be made aware of common neurologic irAEs and able to recognize when prompt evaluation and consultation with appropriate specialists are indicated. Symptoms suggestive of encephalitis, myasthenia-gravis or an acute polyradiculopathy such as Guillain-Barre Syndrome (GBS) in patients exposed to these agents warrant immediate attention with a low threshold for hospitalization to expedite work-up and monitor for severe and/or life-threatening manifestations.
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Affiliation(s)
- Alexandra M Haugh
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John C Probasco
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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184
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Bruna J, Argyriou AA, Anastopoulou GG, Alemany M, Nadal E, Kalofonou F, Piulats JM, Simó M, Velasco R, Kalofonos HP. Incidence and characteristics of neurotoxicity in immune checkpoint inhibitors with focus on neuromuscular events: Experience beyond the clinical trials. J Peripher Nerv Syst 2020; 25:171-177. [PMID: 32166812 DOI: 10.1111/jns.12371] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/08/2020] [Accepted: 03/09/2020] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are associated with various neurological adverse events (NAEs). We herein explored the incidence and clinical phenotype of immune-related NAEs in cancer patients. Medical records of ICI-treated cancer patients were reviewed between the years 2010 and 2018, with an aim to characterize immuno-related NAEs. A total of 1185 ICIs-treated patients were identified, 63.7% of which were males and 36.3% were females, with a mean age of 63.4 ± 7.3 years. Twenty-four from the overall ICIs-treated patients (2%) developed NAEs. No differences were identified in terms of age, sex, tumor type and class of ICIs between the patients who developed NAEs and those who did not. The median number of cycles of ICI treatment before NAEs onset were 4.5 (1-10), and the median time was 102 days. Peripheral nervous system (PNS) involvement was present in 14 patients (58.4%) and central nervous system (CNS) involvement in 10 (33.3%), including 2 patients with aseptic meningitis and polyradicular involvement. Amongst PNS complications, there were five (20.8%) with axonal sensory neuropathies, four (16.7%) with Guillain-Barre-like syndromes, and four (16.7%) with myositis and/or myasthenic syndromes. The majority of patients with PNS-related NAEs (n = 11; 78.6%) improved after ICIs discontinuation and treatment with immune-modulating therapies. The time to neuromuscular toxicities onset was significantly shorter, compared to CNS NAEs (median 70 vs 119 days, P = .037). Immune-related NAEs mostly present with neuromuscular complications. Discontinuation of ICIs and appropriate treatment should be commenced early throughout the process, in order to maximize a favorable outcome.
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Affiliation(s)
- Jordi Bruna
- Hospital Universitari de Bellvitge-ICO l'Hospitalet, IDIBELL, l'Hospitalet de Llobregat, Unit of Neuro-Oncology, Barcelona, Spain.,Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
| | - Andreas A Argyriou
- Department of Medicine, Division Oncology, Medical School, University Hospital of Patras, Rion-Patras, Greece.,Neurology Department, Saint Andrew's General Hospital of Patras, Patras, Greece
| | - Garifallia G Anastopoulou
- Department of Medicine, Division Oncology, Medical School, University Hospital of Patras, Rion-Patras, Greece
| | - Montse Alemany
- Hospital Universitari de Bellvitge-ICO l'Hospitalet, IDIBELL, l'Hospitalet de Llobregat, Unit of Neuro-Oncology, Barcelona, Spain
| | - Ernest Nadal
- Thoracic Oncology Unit, ICO l'Hospitalet, IDIBELL, l'Hospitalet de Llobregat, Barcelona, Spain
| | - Foteini Kalofonou
- Department of Oncology, Garry Weston Centre, Hammersmith Hospital, Imperial NHS Healthcare Trust, London, UK
| | - Josep M Piulats
- Department of Medical Oncology, ICO l'Hospitalet, IDIBELL, l'Hospitalet de Llobregat, Barcelona, Spain
| | - Marta Simó
- Hospital Universitari de Bellvitge-ICO l'Hospitalet, IDIBELL, l'Hospitalet de Llobregat, Unit of Neuro-Oncology, Barcelona, Spain
| | - Roser Velasco
- Hospital Universitari de Bellvitge-ICO l'Hospitalet, IDIBELL, l'Hospitalet de Llobregat, Unit of Neuro-Oncology, Barcelona, Spain.,Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
| | - Haralabos P Kalofonos
- Department of Medicine, Division Oncology, Medical School, University Hospital of Patras, Rion-Patras, Greece
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185
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Myasthenia gravis with myositis induced by pembrolizumab therapy in a patient with metastatic urothelial carcinoma. Int Cancer Conf J 2020; 9:123-126. [PMID: 32582515 DOI: 10.1007/s13691-020-00408-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/11/2020] [Indexed: 10/24/2022] Open
Abstract
Pembrolizumab is a long-awaited drug for the treatment of metastatic urothelial carcinoma. It is an immune checkpoint inhibitor, which has been shown to trigger new autoimmune disorders. We report a case of pembrolizumab-induced myasthenia gravis that occurred in an 84-year-old Japanese female with metastatic urothelial carcinoma in multiple organs. She developed right ptosis 3 days after the second pembrolizumab treatment. Although prednisolone was administered, her symptoms did not change and dysphagia appeared. She needed the steroid pulse therapy for treatment eventually. On the other hand, 9 weeks after the first pembrolizumab treatment, reductions in the sizes of liver and adrenal metastases was observed. However, unfortunately, the severe immune-related adverse events did not allow her to continue the administration of pembrolizumab for the treatment of multiple metastatic urothelial carcinoma. To our knowledge, this is the first case of myasthenia gravis associated with pembrolizumab treatment against metastatic urothelial carcinoma. In this case, a relationship between immune-related adverse events associated with myasthenia gravis and tumor responses to pembrolizumab was suspected, because marked reductions in the sizes of some metastatic lesions were observed after the administration of only two courses of pembrolizumab.
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186
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Dubey D, David WS, Reynolds KL, Chute DF, Clement NF, Cohen JV, Lawrence DP, Mooradian MJ, Sullivan RJ, Guidon AC. Severe Neurological Toxicity of Immune Checkpoint Inhibitors: Growing Spectrum. Ann Neurol 2020; 87:659-669. [PMID: 32086972 DOI: 10.1002/ana.25708] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
Expanding use of immune-checkpoint inhibitors (ICIs) underscores the importance of accurate diagnosis and timely management of neurological immune-related adverse events (irAE-N). We evaluate the real-world frequency, phenotypes, co-occurring immune-related adverse events (irAEs), and long-term outcomes of severe, grade III to V irAE-N at a tertiary care center over 6 years. We analyze how our experience supports published literature and professional society guidelines. We also discuss these data with regard to common clinical scenarios, such as combination therapy, ICI rechallenge and risk of relapse of irAE-N, and corticosteroid taper, which are not specifically addressed by current guidelines and/or have limited data. Recommendations for management and future irAE-N reporting are outlined. ANN NEUROL 2020;87:659-669.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Department of Neurology, and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - William S David
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Kerry L Reynolds
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Donald F Chute
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Nathan F Clement
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Justine V Cohen
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | - Ryan J Sullivan
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Amanda C Guidon
- Department of Neurology, Massachusetts General Hospital, Boston, MA
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187
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Liu Y, Wu W. Cardiovascular immune-related adverse events: Evaluation, diagnosis and management. Asia Pac J Clin Oncol 2020; 16:232-240. [PMID: 32129935 PMCID: PMC7496884 DOI: 10.1111/ajco.13326] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/28/2020] [Indexed: 12/15/2022]
Abstract
Cardiotoxicities are associated with immune checkpoint inhibitor (ICI) therapy. Recent case series and retrospective studies have shown that cardiac immune‐related adverse events (irAEs) are rare but potentially fatal complications of immunotherapy, with various underlying risk factors such as combinations of different ICIs. High mortality rates and overreactive inflammation have been observed with ICI‐associated cardiotoxicities, highlighting the necessity of baseline and serial evaluations and the identification and management of cardiac irAEs as early as possible. The clinical presentations of irAEs range from asymptomatic cardiac biomarker elevation, myocarditis and pericardial diseases to heart failure and mild to fatal arrhythmia. Troponin measurement and electrocardiogram are sensitive initial tests, whereas cardiac magnetic resonance imaging and endomyocardial biopsy are both gold standard components of the diagnostic criteria. Close monitoring and timely consultation with a cardiologist are important for the diagnosis of ICI‐related cardiotoxicities, with decisions of stopping or rechallenging ICIs and strategies to manage heart injuries. Treatment principles are made according to risk stratifications. The first‐line medication is glucocorticoids of various doses, and the second‐line immunosuppression includes intravenous immunoglobin, antithymocyte globulin and other immunosuppressants, which are recommended in life‐threatening cases or in cases of resistance/no response to steroids.
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Affiliation(s)
- Yingxian Liu
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Wei Wu
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
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188
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Yang H, Yao Z, Zhou X, Zhang W, Zhang X, Zhang F. Immune-related adverse events of checkpoint inhibitors: Insights into immunological dysregulation. Clin Immunol 2020; 213:108377. [PMID: 32135278 DOI: 10.1016/j.clim.2020.108377] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/01/2020] [Accepted: 03/01/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) targeting against programmed cell death-1(PD-1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4) have shown efficacy in cancer treatment. However, a spectrum of immune-related adverse events (irAEs) have raised concerns about their clinical application. IrAEs are distinct from traditional chemo- and radiotherapy-induced toxicities, as they are related in particular to the dysregulation of immune system and autoimmunity. The underlying pathogenesis of irAEs remains elusive. Understanding of the potential underlying mechanism is of great importance for the management of irAEs and the development of new ICIs with insignificant irAEs. In this review, we summarize the current evidence to provide insights into the biological basis of irAEs and provide a potential explanation for their pathogenesis, with focus on the relationship between checkpoint molecules and immune cell regulation.
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Affiliation(s)
- Huaxia Yang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing 100730, China; Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Zhuoran Yao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing 100730, China
| | - Xiaoxiang Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing 100730, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing 100730, China; Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Xuan Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing 100730, China; Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China.
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing 100730, China; Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China.
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189
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Xing Q, Zhang ZW, Lin QH, Shen LH, Wang PM, Zhang S, Fan M, Zhu B. Myositis-myasthenia gravis overlap syndrome complicated with myasthenia crisis and myocarditis associated with anti-programmed cell death-1 (sintilimab) therapy for lung adenocarcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:250. [PMID: 32309397 PMCID: PMC7154453 DOI: 10.21037/atm.2020.01.79] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have improved clinical outcomes with a number of advanced malignancies. However, diverse immune-related adverse events (iRAEs) occurred with the widespread use of ICIs, some of which are rarely and life-threatening. Here we report a 66-year-old patient with lung adenocarcinoma who received two doses of sintilimab, a human monoclonal antibody against programmed cell death-1 (PD-1), experienced a fatal storm of iRAEs. He was admitted to the intensive care unit (ICU) by immune induced-myositis/myocarditis and rhabdomyolysis. Despite immediate immunosuppressive therapy with methylprednisolone (MP) and immunoglobulin intravenously, he developed into myositis-myasthenia gravis (MG) overlap syndrome complicated with myasthenia crisis. We commenced plasma exchange (PLEX), mechanical ventilation, immunosuppressive therapy, as well as other supportive therapies. Three months later, the patient's serum creatine phosphate kinase (CPK) and anti-acetylcholine receptor antibody (anti-AChR-Ab) returned to normal despite tumor progression. Herein we discuss the incidence, operating mechanism and management strategies of the fatal iRAEs. Early admission to the ICU and multidisciplinary collaborative treatment for unstable patients with iRAEs could help to achieve a favorable outcome.
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Affiliation(s)
- Qian Xing
- Department of Anaesthesia, Critical Care and Pain Medicine, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zhong-Wei Zhang
- Department of Anaesthesia, Critical Care and Pain Medicine, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qiong-Hua Lin
- Department of Anaesthesia, Critical Care and Pain Medicine, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Li-Hua Shen
- Department of Anaesthesia, Critical Care and Pain Medicine, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Peng-Mei Wang
- Department of Anaesthesia, Critical Care and Pain Medicine, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Shan Zhang
- Department of Anaesthesia, Critical Care and Pain Medicine, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Ming Fan
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Biao Zhu
- Department of Anaesthesia, Critical Care and Pain Medicine, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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190
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Neurotoxicity associated with cancer immunotherapy: immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy. Curr Opin Neurol 2020; 32:500-510. [PMID: 30893101 DOI: 10.1097/wco.0000000000000686] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICPI) and chimeric antigen receptor T cells (CAR-T) represent novel therapies recently approved to treat a number of human cancers. As both approaches modulate the immune system, they can generate a number of immune-related adverse events (irAEs), including a large spectrum of novel neurological toxicities. These are of special interest given their potential severity and risk of compromising further oncologic treatment. We aim to provide a comprehensive review of the literature and discuss their optimal management. RECENT FINDINGS In contrast to irAEs involving other organs, neurological complications of ICPI are uncommon, may present throughout the course of treatment and involve the peripheral and central nervous system, including polyneuropathy, myositis, myasthenia gravis, demyelinating polyradiculopathy, myelitis, encephalitis and others. If started early, ICPI-related neurologic irAEs are usually responsive to steroids. In contrast, as many as 40% of patients undergoing CAR-T therapy will develop neurologic complications in the form of a cytokine-release-associated encephalopathy. It includes delirium, aphasia, tremor/myoclonus, seizure and seizure-like activity. SUMMARY irAEs associated with CAR-T and ICPI therapy constitute new entities. Early identification and treatment are essential to optimize the functional outcome and further oncologic management of the patient.
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191
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Nguyễn T, Maria ATJ, Ladhari C, Palassin P, Quantin X, Lesage C, Taïeb G, Ayrignac X, Rullier P, Hillaire-Buys D, Lambotte O, Guilpain P, Faillie JL. Rheumatic disorders associated with immune checkpoint inhibitors: what about myositis? An analysis of the WHO’s adverse drug reactions database. Ann Rheum Dis 2020; 81:e32. [DOI: 10.1136/annrheumdis-2020-217018] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/22/2020] [Indexed: 12/31/2022]
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192
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Muscle involvement in myasthenia gravis: Expanding the clinical spectrum of Myasthenia-Myositis association from a large cohort of patients. Autoimmun Rev 2020; 19:102498. [PMID: 32062029 DOI: 10.1016/j.autrev.2020.102498] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
Myastenia-Inflammatory Myopathy (MG-IM) association has been described in less than 50 cases, as isolated reports or in few case series. In most cases, MG and IM onset occur simultaneously even if the overlapping clinical manifestations could lead to delay the diagnosis in the early stage of disease. In these cases, thymic pathology is present in more than 50% of cases. Pathological findings can be consistent of polymyositis (63%), dermatomyositis (25%) or granulomatosis (12%). Accurate clinical manifestations and severity of IM in MG, including muscle specific antibodies (MSA) and muscle MRI, have not been systematically investigated and focal or mild subclinical myositis have not been reported. We observed that focal myositis or asymptomatic CK elevation can also occur in MG. In this review we have also retrospectively re-analyzed the clinical, serological, pathological and muscle imaging data from 13 patients with MG- IM from our cohort of 441 MG patients (2,9%). Clinical onset occurred simultaneously in 10/13 patients, whereas in 2 patients the IM appeared later in MG disease course (range 10-14 years) and conversely in 1 patient MG symptoms occurred later in IM disease course (4 years). Median age at disease onset was 51 year (range 24-73 years) regardless of clinical onset (MG or IM). Median clinical follow-up was 88 months (range 31-237 months). IM was suspected by CK elevation in all patients (ranging 800-3000 UI/L at first detection) and non-fatigable muscle weakness unresponsive to acetylcholinesterase inhibitors. All the patients presented mild to moderate MG symptoms. Three main categories of muscle involvement, sometimes overlapping, were recognizable: distal, proximal and subclinical myositits, leading to three main clinical groups (A,B,C) and two overlapping subgroups (A/B and B/C). Thymus pathology was present in 10/13 patients. Anti-AChR was detected in al all patients associated with anti-Titin and -RyR1 in those patients with thymoma. No MSA, nor MAA antibodies were detected. Muscle biopsy confirmed IM in all patients. In conclusion we redefined the clinical spectrum of muscle involvement in MG-IM association, which represent a continuum among 3 main clinical groups: distal, proximal and subclinical muscle involvement. Minimal muscle involvement and focal myositis could be underestimated among myasthenic patients and early aggressive immunotherapy could be required in focal group.
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193
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Fukazawa R, Takezawa H, Tsuji Y, Noto Y, Banba M, Fujii A. [A case of myasthenia gravis developed during pembrolizumab administration, suggesting an excitation-contraction connection disorder]. Rinsho Shinkeigaku 2020; 60:37-40. [PMID: 31852868 DOI: 10.5692/clinicalneurol.cn-001323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The patient was a 50-year-old woman. Pembrolizumab was started for bladder cancer recurrence. From the day after the second administration, ptosis, diplopia, restriction of eye movement, muscle weakness, fatigue resistance, increase in serum creatine kinase (CK) level, and muscle pain were observed. Tests for anti-acetylcholine receptor (AChR) antibody and anti-muscle specific kinase (MuSK) antibody were negative. Electrophysiological examination of the neuromuscular junction showed negative results, and electromyography revealed no myogenic changes. We considered that the immune checkpoint inhibitor caused neuromuscular damage. The patient's symptoms were gradually improved by immunotherapy, such as steroid and plasma exchange. In this case, tests for the anti-titin antibody, an anti-striational antibody, were positive. We considered that myasthenia gravis-like symptoms and serum CK level elevation might have been caused by impairment of excitation-contraction coupling, and not the neuromuscular junction.
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Affiliation(s)
| | | | - Yukiko Tsuji
- Department of Neurology, Kyoto Prefectural University of Medicine
| | - Yuichi Noto
- Department of Neurology, Kyoto Prefectural University of Medicine
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194
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Abstract
No consensus has been reached on the ideal therapeutic algorithm for myasthenia gravis (MG). Most patients with MG require induction therapy with high doses of corticosteroids and maintenance with an immunosuppressant. Severe cases and acute worsening require intravenous immunoglobulin or plasmapheresis before oral immunosuppressants start having an effect. However, biologics are emerging as important therapeutic tools that promise to provide better corticosteroid sparing effects than standard treatments and can even induce remission. In particular, eculizumab, a monoclonal antibody against complement C5, has been approved by the FDA for refractory MG on the basis of a phase III trial. Rituximab, an anti-CD20 monoclonal antibody that depletes peripheral B cells, has also been effective in many large uncontrolled series, although was not in a small phase III trial. Whether the newer anti-CD20 agents ocrelizumab, ofatumumab, obinutuzumab, ublituximab or inebilizumab will be more effective remains unclear. Belimumab, an antibody against the B cell trophic factor BAFF, was ineffective in phase III trials, and efgartigimod, which depletes antibodies, was effective in a phase II study. Some anti-cytokine agents relevant to MG immunopathogenesis also seem promising. Checkpoint inhibitors can trigger MG in some patients, necessitating early intervention. Increased availability of new biologics provides targeted immunotherapies and the opportunities to develop more specific therapies.
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195
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Nakanishi S, Nishida S, Miyazato M, Goya M, Saito S. A case report of nivolumab-induced myasthenia gravis and myositis in a metastatic renal cell carcinoma patient. Urol Case Rep 2020; 29:101105. [PMID: 31908963 PMCID: PMC6940690 DOI: 10.1016/j.eucr.2019.101105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/10/2019] [Accepted: 12/13/2019] [Indexed: 01/04/2023] Open
Abstract
We present a 78-year-old male with renal cell carcinoma who developed myasthenia gravis complicated by myositis after nivolumab administration, which was verified by the presence of antibodies against the acetylcholine receptor. The initial symptom was posterior neck pain, and biochemical examination of blood showed elevated levels of hepatic enzymes and creatine phosphokinase. The level of antibody against the acetylcholine receptor increased 4.1-fold. His condition progressed rapidly resulting in respiratory failure 15 days after conservative therapy. The onset and progression of MG upon treating patients with the PD-1 inhibitor remains unclear. Post-marketing surveillance data are needed to establish its true incidence. Clinicians using PD-1 inhibitors should keep MG in mind so that appropriate treatment including steroid can be given as soon as possible to limit long-term morbidity and mortality.
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Key Words
- AChR, acetylcholine receptor
- CPK, creatine phosphokinase
- ICI, immune checkpoint inhibitors
- IMDC, International Metastatic RCC Database Consortium
- MG, myasthenia gravis
- PD-1, programmed cell death-1
- PLE, pleura
- PUL, pulmonale
- RCC, renal cell carcinoma
- irAE, immune-related adverse events
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Affiliation(s)
- Shotaro Nakanishi
- Department of Urology, Graduate School of Medicine, University of the Ryukyus, Japan
| | - Sho Nishida
- Department of Urology, Graduate School of Medicine, University of the Ryukyus, Japan
| | - Minoru Miyazato
- Department of Systems Physiology, Graduate School of Medicine, University of the Ryukyus, Japan
| | - Masato Goya
- Department of Urology, Graduate School of Medicine, University of the Ryukyus, Japan
| | - Seiichi Saito
- Department of Urology, Graduate School of Medicine, University of the Ryukyus, Japan
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196
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Cordes LM, Davarpanah NN, Reoma LB, Gasmi B, Quezado M, Khan OI, Nath A, Apolo AB. Neurotoxicities associated with checkpoint inhibitors: Two case reports and a review of the literature. Clin Case Rep 2020; 8:24-32. [PMID: 31998480 PMCID: PMC6982490 DOI: 10.1002/ccr3.2534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/20/2019] [Accepted: 09/03/2019] [Indexed: 01/12/2023] Open
Abstract
We report a case of nivolumab-induced delayed-onset aseptic meningitis and a case of limbic encephalitis and peripheral nerve palsy with toxicity relapse 6 months after initial presentation. The atypical presentations contribute to our knowledge of these rare events and reinforce the necessity for vigilant monitoring and a multidisciplinary treatment approach.
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Affiliation(s)
- Lisa M. Cordes
- Genitourinary Malignancies BranchNational Cancer InstituteNational Institutes of HealthBethesdaMaryland
- Office of Clinical ResearchOffice of the DirectorNational Institutes of HealthBethesdaMaryland
| | - Nicole N. Davarpanah
- Genitourinary Malignancies BranchNational Cancer InstituteNational Institutes of HealthBethesdaMaryland
| | - Lauren B. Reoma
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMaryland
| | - Billel Gasmi
- Laboratory of PathologyNational Cancer InstituteNational Institutes of HealthBethesdaMaryland
| | - Martha Quezado
- Laboratory of PathologyNational Cancer InstituteNational Institutes of HealthBethesdaMaryland
| | - Omar I. Khan
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMaryland
| | - Avindra Nath
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMaryland
| | - Andrea B. Apolo
- Genitourinary Malignancies BranchNational Cancer InstituteNational Institutes of HealthBethesdaMaryland
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197
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Tomisaki I. Editorial Comment to Pembrolizumab-induced myasthenia gravis with myositis and presumable myocarditis in a patient with bladder cancer. IJU Case Rep 2020; 3:20. [PMID: 32743460 PMCID: PMC7292177 DOI: 10.1002/iju5.12132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Ikko Tomisaki
- Department of UrologyUniversity of Occupational and Environmental HealthKitakyushuFukuokaJapan
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198
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Robbins NM, Mozaffar T, Mammen AL, Liewluck T, Guidon A, Lawson VH. Reader response: Pearls & Oy-sters: Pembrolizumab-induced myasthenia gravis. Neurology 2019; 93:183-184. [PMID: 31332091 DOI: 10.1212/wnl.0000000000007845] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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199
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Toi Y, Sugawara S, Sugisaka J, Ono H, Kawashima Y, Aiba T, Kawana S, Saito R, Aso M, Tsurumi K, Suzuki K, Shimizu H, Domeki Y, Terayama K, Nakamura A, Yamanda S, Kimura Y, Honda Y. Profiling Preexisting Antibodies in Patients Treated With Anti-PD-1 Therapy for Advanced Non-Small Cell Lung Cancer. JAMA Oncol 2019; 5:376-383. [PMID: 30589930 DOI: 10.1001/jamaoncol.2018.5860] [Citation(s) in RCA: 216] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Administration of anti-programmed cell death protein 1 (anti-PD-1) is now standard therapy in advanced non-small cell lung cancer (NSCLC). However, immune checkpoint inhibitors, including anti-PD-1, have not been assessed in patients with subclinical disease with advanced NSCLC, and no useful clinical biomarkers have been associated with immune-related adverse events (irAEs) among these patients treated with anti-PD-1. Objective To assess the safety and efficacy of anti-PD-1 treatment in patients with subclinical disease with advanced NSCLC and with or without preexisting autoimmune markers, including rheumatoid factor, antinuclear antibody, antithyroglobulin, and antithyroid peroxidase; and to assess potential clinical biomarkers that may be meaningfully and conveniently associated with clinical benefit or with irAEs following anti-PD-1 treatment. Design, Setting, and Participants This medical records analysis retrospectively evaluated 137 patients who received nivolumab or pembrolizumab monotherapy at Sendai Kousei Hospital in Japan between January 2016 and January 2018. Treatment efficacy and irAEs were evaluated along with candidate factors that may be associated with irAEs. Exposures Absence or presence of specific autoimmune markers and antibodies before treatment. Main Outcomes and Measures Preexisting antibodies and autoimmune markers, progression-free survival (PFS), and irAEs. Results Of 137 patients with advanced NSCLC, 105 were men, the median age was 68 (range, 36-88) years, 99 underwent nivolumab monotherapy, 38 underwent pembrolizumab monotherapy, and 134 had an Eastern Cooperative Oncology Group performance status of 0 or 1. The median PFS was 6.5 (95% CI, 4.4-12.9) months among patients with examined preexisting antibodies and 3.5 (95% CI, 2.4-4.1) months among patients without, suggesting significantly better prognosis in the former. The hazard ratio for disease progression or death in the presence of the examined preexisting antibodies was 0.53 (95% CI, 0.36-0.79; P = .002). The PFS was significantly longer among patients with any preexisting antibodies than among those without. The examined preexisting antibodies (48 patients [73%]) and rheumatoid factor (26 patients [39%]) were more common among patients who developed irAEs. Multivariate analysis indicated that the presence of the examined preexisting antibodies was independently associated with irAEs (odds ratio, 3.25; 95% CI, 1.59-6.65; P = .001). Skin reactions were more frequent among patients with preexisting rheumatoid factor (47% vs 24%, P = .02), whereas thyroid dysfunction was more frequent among patients with preexisting antithyroid antibodies (20% vs 1%, P < .001). Conclusions and Relevance The presence of the examined preexisting antibodies was associated with clinical benefit and with the development of irAEs in patients with NSCLC treated with nivolumab or pembrolizumab. Thus, the presence of these autoimmune markers may help determine the risk-benefit ratio for individual patients with NSCLC, maximizing therapeutic benefits while minimizing irAEs.
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Affiliation(s)
- Yukihiro Toi
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Shunichi Sugawara
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Jun Sugisaka
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Hirotaka Ono
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Yosuke Kawashima
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Tomoiki Aiba
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Sachiko Kawana
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Ryohei Saito
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Mari Aso
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Kyoji Tsurumi
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Kana Suzuki
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Hisashi Shimizu
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Yutaka Domeki
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Keisuke Terayama
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Atsushi Nakamura
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Shinsuke Yamanda
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Yuichiro Kimura
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
| | - Yoshihiro Honda
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Aoba-ku, Sendai, Miyagi, Japan
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200
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Maetani Y, Nezu T, Ueno H, Aoki S, Hosomi N, Maruyama H. Steroid-responsive Nivolumab-induced Involuntary Movement with Anti-thyroid Antibodies. Intern Med 2019; 58:3577-3581. [PMID: 31462589 PMCID: PMC6949439 DOI: 10.2169/internalmedicine.3200-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
We herein report a 68-year-old man with neurologic immune-related adverse events (irAEs) who exhibited nivolumab-induced steroid-responsive progressive ataxia, tremor, and anti-thyroid antibodies. His symptoms matched abnormalities on N-isopropyl-p-(123I)-iodoamphetamine single-photon emission computed tomography (SPECT) and dopamine transporter SPECT. Based on these clinical findings, we diagnosed the patient with a condition similar to the cerebellar type of Hashimoto's encephalopathy with nivolumab-induced anti-thyroid antibodies. Neurologic irAEs can be difficult to diagnose due to their varied clinical courses and lack of specific examinations. Therefore, a comprehensive approach, including assessments of autoantibodies and functional imaging, might be important for the diagnosis of neurologic irAEs.
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Affiliation(s)
- Yuta Maetani
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Faculty of Medicine Graduate School of Biomedical and Health Sciences, Japan
| | - Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Faculty of Medicine Graduate School of Biomedical and Health Sciences, Japan
| | - Hiroki Ueno
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Faculty of Medicine Graduate School of Biomedical and Health Sciences, Japan
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Faculty of Medicine Graduate School of Biomedical and Health Sciences, Japan
| | - Naohisa Hosomi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Faculty of Medicine Graduate School of Biomedical and Health Sciences, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Faculty of Medicine Graduate School of Biomedical and Health Sciences, Japan
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