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Chalan P, Di Dalmazi G, Pani F, De Remigis A, Corsello A, Caturegli P. Thyroid dysfunctions secondary to cancer immunotherapy. J Endocrinol Invest 2018; 41:625-638. [PMID: 29238906 PMCID: PMC5953760 DOI: 10.1007/s40618-017-0778-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/21/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Immunotherapy is a firmly established pillar in the treatment of cancer, alongside the traditional approaches of surgery, radiotherapy, and chemotherapy. Like every treatment, also cancer immunotherapy causes a diverse spectrum of side effects, collectively referred to as immune-related adverse events. OBJECTIVE This review will examine the main forms of immunotherapy, the proposed mechanism(s) of action, and the incidence of thyroid dysfunctions. METHODS A comprehensive MEDLINE search was performed for articles published up to March 30, 2017. RESULTS Following the pioneering efforts with administration of cytokines such as IL-2 and IFN-g, which caused a broad spectrum of thyroid dysfunctions (ranging in incidence from 1 to 50%), current cancer immunotherapy strategies comprise immune checkpoint inhibitors, oncolytic viruses, adoptive T-cell transfer, and cancer vaccines. Oncolytic viruses, adoptive T-cell transfer, and cancer vaccines cause thyroid dysfunctions only rarely. In contrast, immune checkpoint blockers (such as anti-CTLA-4, anti-PD-1, anti-PD-L1) are associated with a high risk of thyroid autoimmunity. This risk is highest for anti-PD-1 and increases further when a combination of checkpoint inhibitors is used. CONCLUSIONS Cancer patients treated with monoclonal antibodies that block immune checkpoint inhibitors are at risk of developing thyroid dysfunctions. Their thyroid status should be assessed at baseline and periodically after initiation of the immunotherapy.
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Affiliation(s)
- P Chalan
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Ross Building-Room 656, 720 Rutland Avenue, Baltimore, MD, 21205, USA
| | - G Di Dalmazi
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Ross Building-Room 656, 720 Rutland Avenue, Baltimore, MD, 21205, USA
- Division of Endocrinology, Department of Medicine and Aging Sciences, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - F Pani
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Ross Building-Room 656, 720 Rutland Avenue, Baltimore, MD, 21205, USA
- Endocrinology Unit, Department of Medical Sciences and Public Health Endocrinology, University of Cagliari, Cagliari, Italy
| | - A De Remigis
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Ross Building-Room 656, 720 Rutland Avenue, Baltimore, MD, 21205, USA
- Department of Medicine, Arco Hospital, Trento, Italy
| | - A Corsello
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Ross Building-Room 656, 720 Rutland Avenue, Baltimore, MD, 21205, USA
- Endocrine Tumor Unit, Department of General Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - P Caturegli
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Ross Building-Room 656, 720 Rutland Avenue, Baltimore, MD, 21205, USA.
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Wang GX, Kurra V, Gainor JF, Sullivan RJ, Flaherty KT, Lee SI, Fintelmann FJ. Immune Checkpoint Inhibitor Cancer Therapy: Spectrum of Imaging Findings. Radiographics 2018; 37:2132-2144. [PMID: 29131763 DOI: 10.1148/rg.2017170085] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Immune checkpoint inhibitors are a new class of cancer therapeutics that have demonstrated striking successes in a rapid series of clinical trials. Consequently, these drugs have dramatically increased in clinical use since being first approved for advanced melanoma in 2011. Current indications in addition to melanoma are non-small cell lung cancer, head and neck squamous cell carcinoma, renal cell carcinoma, urothelial carcinoma, and classical Hodgkin lymphoma. A small subset of patients treated with immune checkpoint inhibitors undergoes an atypical treatment response pattern termed pseudoprogression: New or enlarging lesions appear after initiation of therapy, thereby mimicking tumor progression, followed by an eventual decrease in total tumor burden. Traditional response standards applied at the time of initial increase in tumor burden can falsely designate this as treatment failure and could lead to inappropriate termination of therapy. Currently, when new or enlarging lesions are observed with immune checkpoint inhibitors, only follow-up imaging can help distinguish patients with pseudoprogression from the large majority in whom this observation represents true treatment failure. Furthermore, the unique mechanism of immune checkpoint inhibitors can cause a distinct set of adverse events related to autoimmunity, which can be severe or life threatening. Given the central role of imaging in cancer care, radiologists must be knowledgeable about immune checkpoint inhibitors to correctly assess treatment response and expeditiously diagnose treatment-related complications. The authors review the molecular mechanisms and clinical applications of immune checkpoint inhibitors, the current strategy to distinguish pseudoprogression from progression, and the imaging appearances of common immune-related adverse events. ©RSNA, 2017.
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Affiliation(s)
- Gary X Wang
- From the Departments of Radiology (G.X.W., V.K., S.I.L., F.J.F.) and Medicine (J.F.G., R.J.S., K.T.F.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders 210, Boston, MA 02114
| | - Vikram Kurra
- From the Departments of Radiology (G.X.W., V.K., S.I.L., F.J.F.) and Medicine (J.F.G., R.J.S., K.T.F.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders 210, Boston, MA 02114
| | - Justin F Gainor
- From the Departments of Radiology (G.X.W., V.K., S.I.L., F.J.F.) and Medicine (J.F.G., R.J.S., K.T.F.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders 210, Boston, MA 02114
| | - Ryan J Sullivan
- From the Departments of Radiology (G.X.W., V.K., S.I.L., F.J.F.) and Medicine (J.F.G., R.J.S., K.T.F.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders 210, Boston, MA 02114
| | - Keith T Flaherty
- From the Departments of Radiology (G.X.W., V.K., S.I.L., F.J.F.) and Medicine (J.F.G., R.J.S., K.T.F.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders 210, Boston, MA 02114
| | - Susanna I Lee
- From the Departments of Radiology (G.X.W., V.K., S.I.L., F.J.F.) and Medicine (J.F.G., R.J.S., K.T.F.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders 210, Boston, MA 02114
| | - Florian J Fintelmann
- From the Departments of Radiology (G.X.W., V.K., S.I.L., F.J.F.) and Medicine (J.F.G., R.J.S., K.T.F.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders 210, Boston, MA 02114
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154
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Sosa A, Lopez Cadena E, Simon Olive C, Karachaliou N, Rosell R. Clinical assessment of immune-related adverse events. Ther Adv Med Oncol 2018; 10:1758835918764628. [PMID: 29623110 PMCID: PMC5882039 DOI: 10.1177/1758835918764628] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 02/15/2018] [Indexed: 12/18/2022] Open
Abstract
Immunotherapy through checkpoint inhibitors is now standard practice for a growing number of cancer types, supported by overall improvement of clinical outcomes and better tolerance. One anti-CTLA-4 antibody (ipilimumab), two anti-PD-1 antibodies (pembrolizumab and nivolumab) and three anti-PD-L1 antibodies (atezolizumab, avelumab and durvalumab) have been approved for clear benefits across diverse trials. Adverse events of an immune nature associated with these agents frequently affect the skin, colon, endocrine glands, lungs and liver. Most of these effects are mild and can be managed through transient immunosuppression with corticosteroids, but high-grade events often require hospitalization and specialized treatment. However, since immunotherapy is recent, physicians with clinical experience in the diagnosis and management of immune toxicities are frequently those who actively participated in trials, but many practicing oncologists are still not familiarized with the assessment of these events. This review focuses on the incidence, diagnostic assessment and recommended management of the most relevant immune-related adverse events.
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Affiliation(s)
- Aaron Sosa
- Department of Medical Oncology, Hospital Universitari Sagrat Cor, Viladomat 288, Barcelona 08029, Spain
| | - Esther Lopez Cadena
- Department of Pneumonology, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | | | - Niki Karachaliou
- Department of Medical Oncology, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | - Rafael Rosell
- Department of Medical Oncology, Dr Rosell Oncology Institute, Barcelona, Spain
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155
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Incidence and Management of Immune-Related Adverse Events in Patients Undergoing Treatment with Immune Checkpoint Inhibitors. Curr Oncol Rep 2018; 20:24. [PMID: 29511902 DOI: 10.1007/s11912-018-0671-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The unleashing of the immune system in an effort to fight cancer has proven to be an incredible advance in the war on cancer. However that breakthrough has come with a price in the form of serious and potentially fatal immune-related adverse events (irAEs). RECENT FINDINGS Rapid recognition and early intervention is imperative to avoid significant morbidity and mortality. Additionally, providers need to be aware that there are still new, rare, and long-term emerging irAEs that were not previously reported in clinical trials. Because of the significant difference between irAEs and those caused by chemotherapy and/or targeted therapy, providers must have a thorough understanding of which events would be considered immune related and require treatment. This review will cover descriptions of the most common and uncommon but serious irAEs experienced by patients on immunotherapy, as well as management of these irAEs.
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156
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Inamo J, Kaneko Y, Takeuchi T. Inflammatory tenosynovitis and enthesitis induced by immune checkpoint inhibitor treatment. Clin Rheumatol 2018; 37:1107-1110. [DOI: 10.1007/s10067-018-4035-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/08/2018] [Accepted: 02/12/2018] [Indexed: 01/13/2023]
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Kobayashi T, Iwama S, Yasuda Y, Okada N, Tsunekawa T, Onoue T, Takagi H, Hagiwara D, Ito Y, Morishita Y, Goto M, Suga H, Banno R, Yokota K, Hase T, Morise M, Hashimoto N, Ando M, Kiyoi H, Gotoh M, Ando Y, Akiyama M, Hasegawa Y, Arima H. Patients With Antithyroid Antibodies Are Prone To Develop Destructive Thyroiditis by Nivolumab: A Prospective Study. J Endocr Soc 2018; 2:241-251. [PMID: 29600292 PMCID: PMC5836529 DOI: 10.1210/js.2017-00432] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/01/2018] [Indexed: 12/16/2022] Open
Abstract
Context Immune checkpoint inhibitors, including anti–programmed cell death-1 (PD-1) antibodies, have become promising treatments for a variety of advanced malignancies. However, these medicines can cause immune-related adverse events (irAEs), including endocrinopathies. Objective This study examined the incidence of endocrine irAEs induced by nivolumab. Patients and Main Outcome Measured Sixty-six patients treated with nivolumab at Nagoya University Hospital were prospectively evaluated for pituitary hormones, thyroid function, antithyroid antibodies (Abs), and glucose levels every 6 weeks after the initiation of nivolumab for 24 weeks. Results Four out of 66 patients developed destructive thyroiditis, and three patients developed hypothyroidism requiring levothyroxine replacement. The prevalence of positive anti-thyroglobulin Abs (TgAbs) and/or anti–thyroid peroxidase Abs (TPOAbs) at baseline was significantly higher in the group that developed destructive thyroiditis (3/4) compared with the group that did not develop thyroiditis (3/62; P = 0.002). There were no significant differences in other clinical variables between the groups. There were no endocrine irAEs other than destructive thyroiditis during the 24 weeks. The prevalence of TgAbs and/or TPOAbs at baseline was not associated with the development of other irAEs, including pneumonitis, colitis, or skin reactions. Conclusions Our real-world data showed that destructive thyroiditis was an endocrine irAE that was frequently induced by nivolumab and was significantly associated with positive TgAbs and/or TPOAbs before treatment. Our findings indicate that evaluating these Abs before treatment may help identify patients with a high risk of thyroidal irAEs and may have important clinical benefit.
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Affiliation(s)
- Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Research Center of Health, Physical Fitness and Sports, Nagoya University, Nagoya, Japan
| | - Yoshinori Yasuda
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norio Okada
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taku Tsunekawa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Onoue
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Takagi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Hagiwara
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Ito
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiaki Morishita
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Motomitsu Goto
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoichi Banno
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenji Yokota
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tetsunari Hase
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Morise
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naozumi Hashimoto
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Hitoshi Kiyoi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Momokazu Gotoh
- Department of Urology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichi Ando
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan
| | - Masashi Akiyama
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Yang A, Baxi S, Korenstein D. ClinicalTrials.gov for Facilitating Rapid Understanding of Potential Harms of New Drugs: The Case of Checkpoint Inhibitors. J Oncol Pract 2018; 14:72-76. [PMID: 29298113 DOI: 10.1200/jop.2017.025114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Annie Yang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Shrujal Baxi
- Memorial Sloan Kettering Cancer Center, New York, NY
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159
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Gallo M, Muscogiuri G, Felicetti F, Faggiano A, Trimarchi F, Arvat E, Vigneri R, Colao A. Adverse glycaemic effects of cancer therapy: indications for a rational approach to cancer patients with diabetes. Metabolism 2018; 78:141-154. [PMID: 28993227 DOI: 10.1016/j.metabol.2017.09.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 09/12/2017] [Accepted: 09/19/2017] [Indexed: 12/13/2022]
Abstract
Diabetes and cancer are common, chronic, and potentially fatal diseases that frequently co-exist. Observational studies have reported an increased risk of cancer in patients with diabetes. Furthermore, many patients with cancer already have diabetes, or develop hyperglycaemia as a consequence of the tumor or of cancer therapies, and coexisting diabetes confers a greater risk of mortality for many malignancies. Managing oncologic patients with diabetes is often complicated, since the co-existence of diabetes and cancer poses several complex clinical questions: what level of glycaemic control to achieve, which therapy to use, how to deal with glucocorticoid therapies and artificial nutrition, how diabetes complications can affect cancer management, which drug-drug interactions should be taken into account, or even how to manage diabetes at the end of life. In the clinical setting, both at hospital and at home, there are little agreed, evidence-based guidelines on the best management and criteria upon which clinical decisions should be based. A practical solution lies in the implementation of care networks based on communication and ongoing collaboration between Oncologists, Endocrinologists, and the nursing staff, with the patient at the centre of the care process. This manuscript aims to review the current evidence on the effect of cancer therapies on glucose metabolism and to address some of the more common challenges of diabetes treatment in patients with cancer.
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Affiliation(s)
- Marco Gallo
- Oncological Endocrinology Unit, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy.
| | | | - Francesco Felicetti
- Transition Unit for Childhood Cancer Survivors, Department of Oncology, AOU Cittá della Salute e della Scienza di Torino, Turin, Italy
| | - Antongiulio Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G. Pascale" - IRCCS, Naples, Italy
| | - Francesco Trimarchi
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy
| | - Emanuela Arvat
- Oncological Endocrinology Unit, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Riccardo Vigneri
- Endocrinology, University of Catania, Garibaldi-Nesima Medical Center, Catania, Italy
| | - Annamaria Colao
- Department of Clinical Medicine and Surgery, University "Federico II", Naples, Italy
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160
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O'Malley G, Lee HJ, Parekh S, Galsky MD, Smith CB, Friedlander P, Yanagisawa RT, Gallagher EJ. RAPID EVOLUTION OF THYROID DYSFUNCTION IN PATIENTS TREATED WITH NIVOLUMAB. Endocr Pract 2017; 23:1223-1231. [PMID: 29045188 DOI: 10.4158/ep171832.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the evolution of thyroid dysfunction in a series of patients with cancer treated with the immune checkpoint inhibitor anti-programmed cell death protein-1 (PD-1) monoclonal antibody, nivolumab. METHODS Cases of thyroid dysfunction after initiation of checkpoint inhibitor treatment were identified from the Division of Endocrinology clinical practice at Mount Sinai Hospital, New York from April 2016 to February 2017. Charts were reviewed to identify patients treated with nivolumab with new onset of thyroid dysfunction. RESULTS Nine cases of thyroid function in patients who were treated with nivolumab were identified. There were 4 male and 5 female patients, with a mean age of 66 years (range 50-76 years). Seven patients ultimately developed hypothyroidism. Five of the 7 patients developed abnormal thyroid function tests within the first 90 days of starting therapy (range 21-84 days), 3 of whom had transient hyperthyroidism. Transient hyperthyroidism evolved rapidly to hypothyroidism; elevated thyroid-stimulating hormone (TSH) levels were detected within 16 to 32 days of the last documented low TSH. In the 2 patients without a hyperthyroid phase, TSH levels >50 were found 18 to 28 days after the last normal TSH value. CONCLUSION As the use of immune checkpoint inhibitor therapy increases, the need for prompt diagnosis and treatment of drug-induced thyroid disease will become more important. As illustrated in this case series, in contrast to other causes of auto-immune thyroiditis, hypothyroidism can develop rapidly within 3 months of treatment. Close monitoring is necessary to detect the development of thyroid dysfunction and avoid preventable morbidity. ABBREVIATIONS Anti-TPO Abs = anti-thyroglobulin antibodies; CT = computed tomography; CTLA-4 = cytotoxic T-lymphocyte-associated protein 4; FDA = U.S. Food & Drug Administration; FDG-PET = fluorodeoxyglucose-positron emission tomography; PD-1 = programmed cell death protein-1; PD-L1 = programmed death-ligand 1; T3 = triiodothyronine; T4 = thyroxine; TG = thyroglobulin; TPO = thyroperoxidase; TSH = thyroid-stimulating hormone.
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Hickmott L, De La Peña H, Turner H, Ahmed F, Protheroe A, Grossman A, Gupta A. Anti-PD-L1 atezolizumab-Induced Autoimmune Diabetes: a Case Report and Review of the Literature. Target Oncol 2017; 12:235-241. [PMID: 28255845 DOI: 10.1007/s11523-017-0480-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Programmed cell death-1 and programmed death ligand 1 (PD-1/PD-L1) inhibitors trigger an immune-mediated anti-tumour response by promoting the activation of cytotoxic T lymphocytes. Although proven to be highly effective in the treatment of several malignancies they can induce significant immune-related adverse events (irAEs) including endocrinopathies, most commonly hypophysitis and thyroid dysfunction, and rarely autoimmune diabetes. Here we present the first case report of a patient with a primary diagnosis of urothelial cancer developing PD-L1 inhibitor-induced autoimmune diabetes. A euglycemic 57 year old male presented to clinic with dehydration after the fifth cycle of treatment with the novel PD-L1 inhibitor atezolizumab. Blood tests demonstrated rapid onset hyperglycaemia (BM 24 mmol/L), ketosis and a low C-peptide level (0.65 ng/mL) confirming the diagnosis of type 1 diabetes. He responded well to insulin therapy and was discharged with stable blood glucose levels. Due to the widening use of PD-1/PD-L1 inhibitors in cancer treatment clinicians need to be aware of this rare yet treatable irAE. Given the morbidity and mortality associated with undiagnosed autoimmune diabetes we recommend routine HbA1c and plasma glucose testing in all patients prior to and during treatment with PD-1/PD-L1 inhibitors until more evidence has accumulated on identifying those patients with a pre-treatment risk of such irAEs.
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Affiliation(s)
- Laura Hickmott
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK.
| | - Hugo De La Peña
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Helen Turner
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Fathelrahman Ahmed
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Andrew Protheroe
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Avinash Gupta
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
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Stucci S, Palmirotta R, Passarelli A, Silvestris E, Argentiero A, Lanotte L, Acquafredda S, Todisco A, Silvestris F. Immune-related adverse events during anticancer immunotherapy: Pathogenesis and management. Oncol Lett 2017; 14:5671-5680. [PMID: 29113194 PMCID: PMC5661371 DOI: 10.3892/ol.2017.6919] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/27/2017] [Indexed: 12/20/2022] Open
Abstract
Immunotherapy is one of the most recent systemic treatments to emerge for use in oncology, and is based on the blocking of inhibitory immune checkpoints to potentiate the immune response to cancer. The anti-cytotoxic T lymphocyte-associated antigen-4 antibody ipilimumab and anti-programmed cell death protein 1 antibodies, including nivolumab and pembrolizumab, are currently available and widely used, and other immune-inhibiting antibodies are now under intensive investigation. These antibodies have shown efficacy in a growing number of tumor types, following initial observations of their notable effects in melanoma treatment. Despite the efficacy of these antibodies, their novel mechanisms of action are also associated with a new class of side effects called immune-related adverse events (IRAEs). These side effects do not share a common pathophysiology with other anticancer treatments and, therefore, they often require specific therapies. When detected early and correctly treated, IRAEs are reversible; however, they can become severe and life-threatening if underestimated or inappropriately treated. This review aims to revisit the pathogenesis of IRAEs, with attention to gastrointestinal manifestations, since these are common and potentially dangerous complications of immunotherapy and represent a major cause of treatment discontinuation. Recommendations and guidelines for the management of IRAEs are also presented, in order to provide a clear and applicable algorithm for use by clinicians.
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Affiliation(s)
- Stefania Stucci
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
| | - Raffaele Palmirotta
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
| | - Anna Passarelli
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
| | - Erica Silvestris
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
| | - Antonella Argentiero
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
| | - Laura Lanotte
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
| | - Silvana Acquafredda
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
| | - Annalisa Todisco
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
| | - Franco Silvestris
- Department of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, I-70124 Bari, Italy
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163
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Zafon Llopis C. Inmunoterapia oncológica y endocrinología: una nueva oportunidad para la colaboración multidisciplinar. ENDOCRINOL DIAB NUTR 2017; 64:461-463. [DOI: 10.1016/j.endinu.2017.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/24/2022]
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Gay CL, Bosch RJ, Ritz J, Hataye JM, Aga E, Tressler RL, Mason SW, Hwang CK, Grasela DM, Ray N, Cyktor JC, Coffin JM, Acosta EP, Koup RA, Mellors JW, Eron JJ. Clinical Trial of the Anti-PD-L1 Antibody BMS-936559 in HIV-1 Infected Participants on Suppressive Antiretroviral Therapy. J Infect Dis 2017; 215:1725-1733. [PMID: 28431010 DOI: 10.1093/infdis/jix191] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/17/2017] [Indexed: 01/05/2023] Open
Abstract
Background Reversing immune exhaustion with an anti-PD-L1 antibody may improve human immunodeficiency virus type 1 (HIV-1)-specific immunity and increase clearance of HIV-1-expressing cells. Methods We conducted a phase I, randomized, double-blind, placebo-controlled, dose-escalating study of BMS-936559, including HIV-1-infected adults aged >18 to <70 years on suppressive antiretroviral therapy with CD4+ counts >350 cells/μL and detectable plasma HIV-1 RNA by single-copy assay. Data on single infusions of BMS-936559 (0.3 mg/kg) versus placebo are described. The primary outcomes were safety defined as any grade 3 or greater or immune-related adverse event (AE) and the change in HIV-1 Gag-specific CD8+ T cell responses from baseline to day 28 after infusion. Results Eight men enrolled: 6 received 0.3 mg/kg of BMS-936559, and 2 received placebo infusions. There were no BMS-936559-related grade 3 or greater AEs. In 1 participant, asymptomatic hypophysitis (a protocol-defined immune-related AE) was identified 266 days after BMS-936559 infusion; it resolved over time. The mean percentage of HIV-1 Gag-specific CD8+ T cells expressing interferon γ increased from baseline (0.09%) through day 28 (0.20%; P = .14), driven by substantial increases in 2 participants who received BMS-936559. Conclusions In this first evaluation of an immunologic checkpoint inhibitor in healthy HIV-1-infected persons, single low-dose BMS-936559 infusions appeared to enhance HIV-1-specific immunity in a subset of participants. Clinical Trials Registration NCT02028403.
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Affiliation(s)
- Cynthia L Gay
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Ronald J Bosch
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Justin Ritz
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - Evgenia Aga
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Randall L Tressler
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland.,Columbus Technologies, El Segundo, California
| | | | | | | | | | - Josh C Cyktor
- Department of Medicine, University of Pittsburgh, Pennsylvania
| | - John M Coffin
- Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts
| | - Edward P Acosta
- Department of Pharmacology and Toxicology, University of Alabama School of Medicine, Birmingham
| | | | - John W Mellors
- Department of Medicine, University of Pittsburgh, Pennsylvania
| | - Joseph J Eron
- Department of Medicine, University of North Carolina at Chapel Hill
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165
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Valecha G, Pant M, Ibrahim U, Atallah JP. Immunotherapy-induced autoimmune hypophysitis. J Oncol Pharm Pract 2017; 25:217-220. [PMID: 28825378 DOI: 10.1177/1078155217727142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Autoimmune hypophysitis is an immune-related adverse event of immune checkpoint inhibitors. In this article, we present the case of a 58-year-old female patient who presented to the emergency room with gradually worsening nonspecific symptoms of headache, nausea, vomiting and decreased oral intake of one week duration. The patient had been diagnosed with relapsed extensive stage small cell lung cancer. She was being treated with a combination of ipilimumab and nivolumab after progression on chemotherapy. Gadolinium-enhanced magnetic resonance imaging of head revealed pituitary enlargement up to 1.5 cm and pituitary stalk enlargement up to 4 mm consistent with hypophysitis. The patient was treated with corticosteroids resulting in rapid resolution of her symptoms. The objective of our report is to highlight this rare but important adverse event associated with checkpoint inhibitors, and discuss its clinical features, diagnostic work-up and treatment.
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Affiliation(s)
- Gautam Valecha
- 1 Department of Medicine, 7601 Staten Island University Hospital , NY, USA
| | - Manisha Pant
- 1 Department of Medicine, 7601 Staten Island University Hospital , NY, USA
| | - Uroosa Ibrahim
- 2 Department of Hematology/Oncology, Staten Island University Hospital, NY, USA
| | - Jean P Atallah
- 2 Department of Hematology/Oncology, Staten Island University Hospital, NY, USA
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166
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Illouz F, Briet C, Cloix L, Le Corre Y, Baize N, Urban T, Martin L, Rodien P. Endocrine toxicity of immune checkpoint inhibitors: essential crosstalk between endocrinologists and oncologists. Cancer Med 2017; 6:1923-1929. [PMID: 28719055 PMCID: PMC5548876 DOI: 10.1002/cam4.1145] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/16/2017] [Accepted: 06/21/2017] [Indexed: 12/31/2022] Open
Abstract
Two types of immune checkpoint inhibitors, both antibodies that target cytotoxic T-lymphocyte antigen-4 and those that target programmed cell death-protein 1, have been approved for use in melanoma, non-small-cell lung cancer, and renal cell carcinoma as first-line or second-line therapy. Their adverse events are primarily regarded as immune-related adverse events. We felt it was important to pinpoint and discuss certain preconceptions or misconceptions regarding thyroid dysfunction, hypophysitis, and diabetes induced by immune checkpoint inhibitors. We have identified areas of uncertainty and unmet requirements, including essential interaction between endocrinologists and oncologists. Five issues have been identified for discussion: (1) diagnosis of endocrine toxicity, (2) assessment of toxicity severity, (3) treatment of toxicity, (4) withdrawal or continuation of immunotherapy, (5) preventive action.
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Affiliation(s)
- Frédéric Illouz
- Department of Endocrinology, Diabetes and Nutrition, Reference Centre of Rare Thyroid Disease, Hospital of Angers, Angers Cedex 09, F-49933, France
| | - Claire Briet
- Department of Endocrinology, Diabetes and Nutrition, Reference Centre of Rare Thyroid Disease, Hospital of Angers, Angers Cedex 09, F-49933, France.,MITOVASC Institute, INSERM U1083, University of Angers, Angers Cedex 09, F-49933, France
| | - Lucie Cloix
- Department of Endocrinology, Hospital of Orléans, Orléans, F-45000, France
| | - Yannick Le Corre
- Department of Dermatology, Hospital of Angers, University of Angers, Angers Cedex 09, F-49933, France
| | - Nathalie Baize
- UTTIOM Unit for Innovate Therapy in Medical Oncology, Hospital of Angers, Angers Cedex 09, F-49933, France
| | - Thierry Urban
- Department of Pulmonology and Thoracic Oncology, Hospital of Angers, Angers Cedex 09, F-49933, France.,INSERM UMRS 1066, University of Angers, Angers Cedex 09, F-49933, France
| | - Ludovic Martin
- Department of Dermatology, Hospital of Angers, University of Angers, Angers Cedex 09, F-49933, France
| | - Patrice Rodien
- Department of Endocrinology, Diabetes and Nutrition, Reference Centre of Rare Thyroid Disease, Hospital of Angers, Angers Cedex 09, F-49933, France.,MITOVASC Institute, INSERM U1083, University of Angers, Angers Cedex 09, F-49933, France
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167
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Abstract
Immunotherapy is an evolving modality in the treatment of non-Hodgkin lymphoma. Vaccinations with patient-specific tumor-derived antigens have been developed to strengthen immune response to tumor. The success of rituximab, a monoclonal antibody for CD20 on malignant B-cells, fueled further immunotherapy research. The power of the immune system to fight hematologic malignancies is seen in allogeneic stem cell transplant, where donor T cells attack residual malignant cells in the recipient. Now, three innovative therapeutic immunotherapy classes (I) adoptive cellular therapy; (II) immune-checkpoint inhibitors; and (III) novel antibody therapies show promising results in non-Hodgkin lymphoma. Genetically engineered T cells, CAR T cells, obtained remissions in lymphomas refractory to conventional chemotherapy. Immune-checkpoint inhibitors, such as nivolumab and pembrolizumab revolutionized the treatment of many solid tumors, and unprecedented results are now reported in relapsed/refractory lymphoma. Building on the success of rituximab, additional therapeutic monoclonal antibodies were developed for lymphoma treatment. Antibodies have recently been further engineered with multiple binding sites to directly engage both tumor and T cells. There are exciting early clinical trial results for the first bispecific T-cell engager (BiTE), blinatumomab, as well as promising ongoing studies for dual antibody molecules, Dual-Affinity Re-Targeting (DART) proteins. This review highlights these three immunotherapy classes for relapsed/refractory non-Hodgkin lymphomas and discusses the mechanism of action, clinical efficacy, and toxicities of each.
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Affiliation(s)
- Allyson Pishko
- Division of Hematology/Oncology, Department of Medicine and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunita D Nasta
- Division of Hematology/Oncology, Department of Medicine and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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168
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Socinski MA, Pennell NA. Best Practices in Treatment Selection for Patients With Advanced NSCLC. Cancer Control 2017; 23:2-14. [PMID: 27842052 DOI: 10.1177/1073274816023004s01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Worldwide, lung cancer is the most prevalent form of cancer, and its non-small-cell subtype constitutes up to 85% of cases. Overall, lung cancer is the most common cause of cancer-related death in the United States for both sexes, and its 5-year survival rate is 17%. It is a heterogeneous disease characterized by a variety of biomarkers and differing histologies. Non-small-cell lung cancer may be squamous or nonsquamous in nature and fueled by a number of oncodrivers. Obtaining sufficient tissue during biopsy to perform thorough biomarker testing is a challenge but essential for the modern, targeted therapeutic environment. Although platinum-based doublets still play a major role in first-line treatment, novel therapeutic agent targeting BRAF, EGFR, ALK, and ROS1, as well as agents targeting the T790M mutation, may offer options for patients whose disease fails to respond to initial therapy or relapses following an initial response. The emergence of immunotherapy as second-line standard therapy has changed the treatment paradigm. Some patients will have more favorable outcomes in the first-line setting with immunotherapy. However, managing lung cancer has become more complex than it was 15 years ago when the challenge of treatment was seen as being only binary, ie, small-cell vs non-small-cell disease.
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169
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Senant M, Giusti D, Weiss L, Dragon-Durey MA. Auto-immunité et gestion des toxicités des traitements par anti-check point inhibiteurs. Bull Cancer 2017; 103 Suppl 1:S175-S185. [PMID: 28057182 DOI: 10.1016/s0007-4551(16)30376-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AUTOIMMUNITY AND MANAGEMENT OF THE IMMUNE-RELATED ADVERSE EFFECTS OF THE IMMUNE CHECKPOINT INHIBITORS: The immune checkpoint molecules such as CTLA-4 and PD-1 are involved in the tolerance mechanisms preventing the immune system to react against the self-antigens. When these receptors expressed on the lymphocyte membrane, bind to their ligands, they induce a negative signal to the cell which becomes unable to be completely activated in the presence of its antigen. In a context of tumor, the infiltrating T cells are frequently exhausted due to the expression of CTLA-4 and PD-1 ligands by the microenvironment impairing the antitumoral immunity. The use of antagonistic antibodies targeting these receptors or their ligands (called checkpoint inhibitors) aims to block their interaction unbalancing the negative regulation of the antitumoral lymphocytes. However, this effect affects all lymphocytes and may also disrupt the negative regulation of the peripheral autoreactive lymphocytes. Thus, a significant proportion of patients treated by these molecules develop immune-related symptoms affecting different tissues and organs due to lymphocyte activation. These symptoms are called immune-related adverse events (irAEs). This article aims to summarize the scientific data demonstrating the implication of these molecules in the tolerance mechanisms and in the autoimmune diseases. It also reports on the IrAEs observed in treated patients and gives an outline of guidelines to monitor and manage these patients.
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Affiliation(s)
- Marie Senant
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service d'immunologie biologique, hôpital européen Georges-Pompidou, Assistance publique-hôpitaux de Paris.
| | - Delphine Giusti
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service d'immunologie biologique, hôpital européen Georges-Pompidou, Assistance publique-hôpitaux de Paris.
| | - Laurence Weiss
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service d'immunologie clinique, hôpital européen Georges-Pompidou, Assistance publique-hôpitaux de Paris
| | - Marie-Agnès Dragon-Durey
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service d'immunologie biologique, hôpital européen Georges-Pompidou, Assistance publique-hôpitaux de Paris
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170
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Braschi-Amirfarzan M, Tirumani SH, Hodi FS, Nishino M. Immune-Checkpoint Inhibitors in the Era of Precision Medicine: What Radiologists Should Know. Korean J Radiol 2017; 18:42-53. [PMID: 28096717 PMCID: PMC5240494 DOI: 10.3348/kjr.2017.18.1.42] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/11/2016] [Indexed: 12/15/2022] Open
Abstract
Over the past five years immune-checkpoint inhibitors have dramatically changed the therapeutic landscape of advanced solid and hematologic malignancies. The currently approved immune-checkpoint inhibitors include antibodies to cytotoxic T-lymphocyte antigen-4, programmed cell death (PD-1), and programmed cell death ligand (PD-L1 and PD-L2). Response to immune-checkpoint inhibitors is evaluated on imaging using the immune-related response criteria. Activation of immune system results in a unique toxicity profile termed immune-related adverse events. This article will review the molecular mechanism, clinical applications, imaging of immune-related response patterns and adverse events associated with immune-checkpoint inhibitors.
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Affiliation(s)
- Marta Braschi-Amirfarzan
- Department of Radiology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA 02215, USA
| | - Sree Harsha Tirumani
- Department of Radiology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA 02215, USA
| | - Frank Stephen Hodi
- Department of Medical Oncology and Medicine, Dana Farber Cancer Institue, Boston, MA 02215, USA
| | - Mizuki Nishino
- Department of Radiology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA 02215, USA
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