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Li Y, Zhao J, Wang Y, Xu Y, Li R, Zhao Y, Dong X, Yao X, Li Y. Common endocrine system adverse events associated with immune checkpoint inhibitors. CANCER PATHOGENESIS AND THERAPY 2024; 2:164-172. [PMID: 39027145 PMCID: PMC11252504 DOI: 10.1016/j.cpt.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 07/20/2024]
Abstract
Immune checkpoint inhibitors (ICIs), a novel anti-tumor therapeutic modality, are monoclonal antibodies targeting certain immune checkpoints (ICs) that reactivate T cells to achieve anti-tumor immunity by targeting, binding, and blocking ICs. Targeted inhibitory antibodies against the ICs cytotoxic T-lymphocyte antigen and programmed death receptor-1 have demonstrated efficacy and durable anti-tumor activity in patients with cancer. ICs may prevent autoimmune reactions. However, ICIs may disrupt ICs properties and trigger autoimmune-related adverse reactions involving various organ systems including the cardiovascular, pulmonary, gastrointestinal, renal, musculoskeletal, dermal, and endocrine systems. Approximately 10% of patients with damage to target organs such as the thyroid, pituitary, pancreas, and adrenal glands develop endocrine system immune-related adverse events (irAEs) such as thyroid dysfunction, pituitary gland inflammation, diabetes mellitus, and primary adrenal insufficiency. However, the symptoms of immunotherapy-associated endocrine system irAEs may be nonspecific and similar to those of other treatment-related adverse reactions, and failure to recognize them early may lead to death. Timely detection and treatment of immunotherapy-associated endocrine irAEs is essential to improve the efficacy of immunotherapy, prognosis, and the quality of life of patients. This study aimed to review the mechanisms by which ICIs cause endocrine irAEs providing guidance for the development of appropriate management protocols. Here, we discuss (1) the biological mechanisms of ICs in tumorigenesis and progression, focusing on cytotoxic T-lymphocyte antigen and programmed cell death-1/programmed cell death-ligand 1; and (2) the epidemiology, clinical symptoms, diagnosis, and treatment of four immunotherapy-related endocrine complications.
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Affiliation(s)
- Ying Li
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, Shandong 250000, China
| | - Junfeng Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, Shandong 250000, China
| | - Yue Wang
- National Institutes for Food and Drug Control, Beijing 102629, China
| | - Yali Xu
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250000, China
| | - Ruyue Li
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, Shandong 261000, China
| | - Ying Zhao
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, Shandong 250000, China
| | - Xue Dong
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, Shandong 250000, China
| | - Xiujing Yao
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, Shandong 261000, China
| | - Yintao Li
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, Shandong 250000, China
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Yan J, Xie ZZ, Moran T, Gridelli C, Zheng MD, Dai SJ. Diabetic ketoacidosis induced by nivolumab in invasive mucinous adenocarcinoma of the lung: a case report and review of the literature. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1256. [PMID: 36544678 PMCID: PMC9761142 DOI: 10.21037/atm-22-5211] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022]
Abstract
Background Nivolumab is the first programmed cell death receptor 1 (PD-1) inhibitor approved in China. Compared with chemotherapy, nivolumab has shown advantages of good efficacy and safety in the treatment of a variety of tumors. However, due to its short time of use in China and lack of safety experience, clinical understanding of its adverse reactions has not been sufficiently elucidated. In recent years, cases of diabetic ketoacidosis caused by nivolumab have been reported in the emergency department, which has aroused our concern. Case Description Here we present a serious case of diabetic ketoacidosis in a 69-year-old woman with invasive mucinous adenocarcinoma of the lung, which occurred following therapy with the PD-1 inhibitor nivolumab and dendritic cell/cytokine-induced killer cell (DC/CIK) immunotherapy. She presented with diabetic ketoacidosis 5 days after the second cycle of nivolumab administration. The patient presented with dry mouth symptoms, a maximum blood glucose of 511.2 mg/dL, hemoglobin A1c (HbA1c) level of 7.4%, urine ketone body value of 3+, and extracellular fluid residual alkali level of -3.8 mmol/L. Normal saline and insulin was initiated. The patient had no history of obesity or family history of diabetes. She received a single dose of 3.75 mg of dexamethasone treatment during this period of time which resulted in cough improvement, but did not explain the onset of the diabetes. She was treated with insulin, sitagliptin phosphate tablets and acarbose tablets. Diabetic ketoacidosis was considered an immune-related toxicity caused by nivolumab, and consequently, treatment with nivolumab was suspended. Patient was maintained under insulin treatment with a blood glucose levels normalization. Conclusions The incubation period of nivolumab-induced diabetic ketoacidosis is dispersive and the clinical risk is high. Patients need life-long insulin therapy. Blood glucose and HbA1c should be monitored routinely before and during nivolumab immunotherapy to avoid the occurrence of diabetic ketoacidosis. After the occurrence of diabetic ketoacidosis, insulin should be used to actively control blood glucose and do a good job in medication education to ensure long-term compliance of patients. Nivolumab should only be initiated if the patient has a clinical benefit under stable glucose control.
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Affiliation(s)
- Juan Yan
- Department of Pharmacy, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Zheng-Zheng Xie
- Department of Pharmacy, Beijing Shijitan Hospital, Beijing, China
| | - Teresa Moran
- Medical Oncology Department, Catalan Institute of Oncology Badalona, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain;,Institut Germans Trias i Pujol, Barcelona, Spain;,Badalona Applied Research Group in Oncology, Barcelona, Spain;,Department of Medicine, Universitat Autònoma de Barcelona (UAB), Campus Can Ruti, Barcelona, Spain
| | - Cesare Gridelli
- Division of Medical Oncology, ‘S. G. Moscati’ Hospital, Avellino, Italy
| | - Mao-Dong Zheng
- Department of Pharmacy, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Su-Juan Dai
- Department of Pharmacy, Zengchen District People’s Hospital of Guangzhou (Boji-Affiliated Hospital of Sun Yat-sen University), Guangzhou, China
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Yin N, Liu X, Ye X, Song W, Lu J, Chen X. PD-1 inhibitor therapy causes multisystem immune adverse reactions: a case report and literature review. Front Oncol 2022; 12:961266. [PMID: 36119464 PMCID: PMC9478917 DOI: 10.3389/fonc.2022.961266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors(ICIs), including cytotoxic T-lymphocyte antigen 4 (anti-CTLA-4), programmed cell death protein 1 and its ligand (PD-1/PD-L1) inhibitors, have been shown to have antitumor activity in various solid tumors. Their mechanism of action is to selectively restore and normalize the body’s immune reponses by disrupting the immunosuppressive signals mediated by PD-1, PD-L1 and CTLA-4 in the tumor microenvironment. With the increase in clinical applications of ICIs, reports of immune-related adverse events (irAEs) have also increased. This article reports a case of a lung cancer patient who developed multisystemic adverse effects after PD-1 inhibitor application: myocarditis, myositis and thrombocytopenia, and analyzes the role of Interleukin 6(IL-6)in the management of irAEs. Despite the patient’s eventual discontinuation of antitumor therapy due to severe irAEs, a significant and durable therapeutic response was observed.
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Druce I, Tawagi K, Shaw JLV, Ibrahim A, Lochnan H, Ong M. Routine Screening for Central and Primary Adrenal Insufficiency during Immune-Checkpoint Inhibitor Therapy: An Endocrinology Perspective for Oncologists. Curr Oncol 2022; 29:4665-4677. [PMID: 35877230 PMCID: PMC9315594 DOI: 10.3390/curroncol29070370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Immune checkpoint inhibitor (ICI)-associated hypothalamic–pituitary–adrenal axis disruption can lead to hypocortisolism. This is a life-threatening but difficult to diagnose condition, due to its non-specific symptoms that overlap with symptoms of malignancy. Currently, there is no consensus on how to best screen asymptomatic patients on ICI therapy for hypophysitis with serum cortisol. Methods: A retrospective chart review of patients treated with ICI in a tertiary care centre was conducted to assess the rate of screening with cortisol and whether this had an impact on diagnosis of ICI-hypophysitis in the preclinical stage. Patients were identified as having hypophysitis with an adrenocorticotropin hormone (ACTH) deficiency based on chart review of patients with cortisol values ≤ 140 nmol/L (≤5 mcg/dL). We also assessed what proportion of cortisol values were drawn at the correct time for interpretation (between 6 AM and 10 AM). Results: Two hundred and sixty-five patients had 1301 cortisol levels drawn, only 40% of which were drawn correctly (between 6 and 10 AM). Twenty-two cases of hypophysitis manifesting with ACTH deficiency were identified. Eight of these patients were being screened with cortisol following treatment and were detected in the outpatient setting. The remaining 14 patients were not screened and were diagnosed when symptomatic, after an emergency room visit or hospital admission. Sixty percent of the cortisol tests were uninterpretable as they were not drawn within the appropriate time window. Conclusion: Measuring morning serum cortisol in asymptomatic patients on ICI therapy is a fast and inexpensive way to screen for hypophysitis and should become the standard of care. Random serum cortisol measurement has no clinical value. Education needs to be provided on when to correctly perform the test and how to interpret it and we provide an algorithm for this purpose. The adoption and validation of such an algorithm as part of routine practice could significantly reduce morbidity and mortality in patients, especially as ICI therapy is becoming increasingly commonplace.
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Affiliation(s)
- Irena Druce
- Division of Endocrinology and Metabolism, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON KIH8L6, Canada;
- Correspondence:
| | - Karine Tawagi
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON KIH8L6, Canada; (K.T.); (A.I.); (M.O.)
| | - Julie L. V. Shaw
- Department of Pathology and Laboratory Medicine, Eastern Ontario Regional Laboratories Association, The Ottawa Hospital Research Institute, The Ottawa Hospital, The University of Ottawa, Ottawa, ON KIH8L6, Canada;
| | - Andrea Ibrahim
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON KIH8L6, Canada; (K.T.); (A.I.); (M.O.)
| | - Heather Lochnan
- Division of Endocrinology and Metabolism, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON KIH8L6, Canada;
| | - Michael Ong
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON KIH8L6, Canada; (K.T.); (A.I.); (M.O.)
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Karhapää H, Mäkelä S, Laurén H, Jaakkola M, Schalin-Jäntti C, Hernberg M. Immune checkpoint inhibitors, endocrine adverse events, and outcomes of melanoma. Endocr Connect 2022; 11:e210562. [PMID: 35015699 PMCID: PMC8859941 DOI: 10.1530/ec-21-0562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/11/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICI) can cause endocrine adverse events. However, endocrine adverse events (AEs). However, endocrine AEs could be related to better treatment outcomes. Our aim was to investigate whether this holds true in a real-world setting of metastatic melanoma patients. DESIGN A retrospective single-institution study. METHODS We included 140 consecutive metastatic melanoma patients treated with ICI between January 2012 and May 2019. We assessed the endocrine toxicity and the best possible treatment outcomes from electronic patient records, including laboratory parameters and radiological images. RESULTS Of the treated patients, 21 patients (15%) were treated with ipilimumab, 46 (33%) with nivolumab, 67 (48%) with pembrolizumab, and 6 (4%) with combination therapy (ipilimumab + nivolumab). Endocrine AEs appeared in 29% (41/140) patients. Three patients had two different endocrine AEs. Thyroid disorders were the most common: 26% (36/140), followed by hypophysitis: 4% (5/140). Three subjects (2%, 3/140) were diagnosed with autoimmune diabetes. Three patients had to terminate treatment due to endocrine toxicity. Radiological manifestations of endocrine AEs were found in 16 patients (39%, 16/41). Endocrine toxicity was associated with significantly better treatment outcomes. Median progression-free survival (8.1 months, range 5.1-11.1 months vs 2.7 months, range 2.4-3.0 months, P < 0.001), and median overall survival (47.5 months, range 15.5-79.5 months vs 23.7 months, range 15.3-32.1 months, P = 0.035) were longer for patients experiencing endocrine AEs. CONCLUSIONS The higher number of endocrine AEs suggest that regular laboratory monitoring aids in AE detection. Endocrine AEs in metastatic melanoma may correlate with better treatment outcomes.
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Affiliation(s)
- Hanna Karhapää
- Medical Faculty, University of Helsinki, Helsinki, Finland
- Department of Oncology, Comprehensive Cancer Centre, Helsinki University Hospital, Helsinki, Finland
- Correspondence should be addressed to H Karhapää:
| | - Siru Mäkelä
- Medical Faculty, University of Helsinki, Helsinki, Finland
- Department of Oncology, Comprehensive Cancer Centre, Helsinki University Hospital, Helsinki, Finland
| | - Hanna Laurén
- Medical Faculty, University of Helsinki, Helsinki, Finland
- Department of Radiology, HUS Medical Imaging Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Jaakkola
- Medical Faculty, University of Helsinki, Helsinki, Finland
- Department of Radiology, HUS Medical Imaging Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Camilla Schalin-Jäntti
- Medical Faculty, University of Helsinki, Helsinki, Finland
- Endocrinology, Abdominal Centre, University of Helsinki and HUS, Helsinki, Finland
| | - Micaela Hernberg
- Medical Faculty, University of Helsinki, Helsinki, Finland
- Department of Oncology, Comprehensive Cancer Centre, Helsinki University Hospital, Helsinki, Finland
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Chera A, Stancu AL, Bucur O. Thyroid-related adverse events induced by immune checkpoint inhibitors. Front Endocrinol (Lausanne) 2022; 13:1010279. [PMID: 36204105 PMCID: PMC9530140 DOI: 10.3389/fendo.2022.1010279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/29/2022] [Indexed: 11/24/2022] Open
Abstract
Immune checkpoint inhibitors, namely anti-CTLA-4, anti-PD-1 and anti-PD-L1 monoclonal antibodies, have emerged in the last decade as a novel form of cancer treatment, promoting increased survival in patients. As they tamper with the immune response in order to destroy malignant cells, a new type of adverse reactions has emerged, known as immune-related adverse events (irAEs), which frequently target the endocrine system, especially the thyroid and hypophysis. Thyroid irAEs include hyperthyroidism, thyrotoxicosis, hypothyroidism and a possibly life-threatening condition known as the "thyroid storm". Early prediction of occurrence and detection of the thyroid irAEs should be a priority for the clinician, in order to avoid critical situations. Moreover, they are recently considered both a prognostic marker and a means of overseeing treatment response, since they indicate an efficient activation of the immune system. Therefore, a multidisciplinary approach including both oncologists and endocrinologists is recommended when immune checkpoint inhibitors are used in the clinic.
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Affiliation(s)
- Alexandra Chera
- Victor Babes National Institute of Pathology, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Andreea Lucia Stancu
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Octavian Bucur
- Victor Babes National Institute of Pathology, Bucharest, Romania
- Viron Molecular Medicine Institute, Boston, MA, United States
- *Correspondence: Octavian Bucur, ;;
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Dyrka K, Witasik D, Czarnywojtek A, Łącka K. The influence of monoclonal antibodies for cancer
treatment on the endocrine system. POSTEP HIG MED DOSW 2021. [DOI: 10.5604/01.3001.0014.8889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cancer is one of the main causes of mortality worldwide. Thanks to scientific research, new
methods of cancer treatment, including molecularly targeted therapy, are being developed.
Monoclonal antibodies are used to treat many diseases, including some types of cancer, and
affect various systems of the human body. The presented article aims to present the adverse
effects of molecularly targeted cancer therapy on the endocrine system based on the current
literature data. Immune checkpoint inhibitors, such as anti-CTLA-4 and anti-PD-1 or its
ligand PD-L1, can cause a variety of autoimmune adverse effects, among others, thyroid dysfunction,
hypophysitis, and diabetes mellitus. The authors also paid attention to monitoring
selected diagnostic parameters to prevent endocrine adverse effects during a therapy with
monoclonal antibodies. The development of adverse effects may sometimes progress atypically
and rapidly, and may be a life-threatening condition. Clinicians should choose individual
schemes of treatment for particular patients. The patient’s condition should also be monitored
before, during and after the therapy. The decision about the continuation of treatment with
monoclonal antibodies should be based especially on a risk connected with the cessation of
treatment. Clinical trials should be continued to improve knowledge about the side effects of
monoclonal antibodies.
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Affiliation(s)
- Kamil Dyrka
- Student’s Scientific Group of Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Daria Witasik
- Student’s Scientific Group of Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Agata Czarnywojtek
- Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | - Katarzyna Łącka
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
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Endocrine Toxicities of Antineoplastic Therapy. Cancers (Basel) 2021; 13:cancers13020294. [PMID: 33466843 PMCID: PMC7830439 DOI: 10.3390/cancers13020294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/12/2021] [Indexed: 11/16/2022] Open
Abstract
In recent years, the prognosis of many solid tumors has improved markedly thanks to new treatment strategies, including tyrosine kinase inhibitors (TKIs) and immunotherapy [...].
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Zheng Z, Liu Y, Yang J, Tan C, Zhou L, Wang X, Xiao L, Zhang S, Chen Y, Liu X. Diabetes mellitus induced by immune checkpoint inhibitors. Diabetes Metab Res Rev 2021; 37:e3366. [PMID: 32543027 DOI: 10.1002/dmrr.3366] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/22/2020] [Accepted: 06/12/2020] [Indexed: 02/05/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are widely used in oncology for their favourable antitumor efficacy. ICI therapy is associated with a unique toxicity profile known as immune-related adverse events (irAEs). One such irAE is ICI-related diabetes mellitus (DM), which is relatively uncommon but can become extremely severe, leading to irreversible impairment of β-cells, and even lead to death if not promptly recognised and properly managed. The precise mechanisms of ICI-related DM are not well understood. In this review, we summarise the clinical characteristics, pathophysiology, and management of this adverse effect caused by ICI therapy. Deeper investigation of ICI-related DM may contribute to elucidate the molecular mechanisms of classical type 1 DM.
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Affiliation(s)
- Zhenjiang Zheng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ya Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Yang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chunlu Tan
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Li Zhou
- Research Core Facility of West China Hospital, Sichuan University, Chengdu, China
| | - Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Li Xiao
- Department of Traditional Chinese Medicine, Chengdu Third People's Hospital, Chengdu, China
| | - Shu Zhang
- Department of General Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Yonghua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xubao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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El Sabbagh R, Azar NS, Eid AA, Azar ST. Thyroid Dysfunctions Due to Immune Checkpoint Inhibitors: A Review. Int J Gen Med 2020; 13:1003-1009. [PMID: 33177863 PMCID: PMC7650809 DOI: 10.2147/ijgm.s261433] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/01/2020] [Indexed: 11/23/2022] Open
Abstract
Aim Immune checkpoint inhibitors are anti-cancer drugs associated with adverse events that result from releasing the immune system against self-antigens while attacking cancer cells. Thyroid dysfunctions are among the most common associated adverse events. Materials and Methods We conducted a systematic search of the literature in 2 databases: PubMed and Medline. Articles that reported thyroid adverse events of immune checkpoint inhibitors were reviewed. Thyroid disorders include hyperthyroidism and hypothyroidism and are most commonly seen with programmed cell death protein 1 and programmed death-ligand 1 inhibitors. Conclusions Thyroid disorders are common side effects seen with check point inhibitors and are treated, depending on the clinical situation, by adequate hormonal replacement, thionamides, corticosteroids or observation only. The use of high dose corticosteroids has not been established as a treatment of thyroid toxicities. Thyroid function tests screening should be a part of baseline laboratory testing of all patients undergoing treatment with immune checkpoint inhibitors.
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Affiliation(s)
- Rawaa El Sabbagh
- Division of Endocrinology and Metabolism, American University of Beirut, Beirut, Lebanon
| | - Nadim S Azar
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.,Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Assaad A Eid
- Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Sami T Azar
- Division of Endocrinology and Metabolism, American University of Beirut, Beirut, Lebanon
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du Payrat JA, Cugnet-Anceau C, Maillet D, Levy M, Raverot G, Disse E, Borson-Chazot F. Hypophysites induites par les immunothérapies anti-néoplasiques. Bull Cancer 2020; 107:490-498. [DOI: 10.1016/j.bulcan.2020.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/17/2019] [Accepted: 01/05/2020] [Indexed: 10/24/2022]
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Simmons CE, Brezden-Masley C, McCarthy J, McLeod D, Joy AA. Positive progress: current and evolving role of immune checkpoint inhibitors in metastatic triple-negative breast cancer. Ther Adv Med Oncol 2020; 12:1758835920909091. [PMID: 33014143 PMCID: PMC7517981 DOI: 10.1177/1758835920909091] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/20/2020] [Indexed: 12/31/2022] Open
Abstract
Background: Triple-negative breast cancer (TNBC) represents an aggressive breast cancer subtype with historically poor overall outcomes, due primarily to a lack of effective targeted agents. Chemotherapy has been the primary treatment approach, although immune checkpoint inhibitors (ICIs) are currently being investigated to improve patient outcomes. This review examines the clinical implications of current evidence on the use of ICIs for the treatment of metastatic TNBC. Methods: Our systematic search identified two phase III and five phase I/II trials reporting on the efficacy of ICIs used as monotherapy or combined with chemotherapy for the treatment of metastatic TNBC. Results: The phase III IMpassion 130 trial showed a significant improvement in median progression-free survival in the intent-to-treat (net 1.7 months, p = 0.002) and PD-L1-positive populations (net 2.5 months, p < 0.001) for the addition of first-line atezolizumab versus placebo to nab-paclitaxel in metastatic TNBC. Although median overall survival was not significantly improved in patients receiving atezolizumab overall [net 2.3 months, hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.72–1.02, p = 0.078], numerical improvements in the PD-L1-positive population were compelling (net 7.0 months, HR 0.71; 95% CI 0.54–0.93). Toxicity profiles were as expected, and no new safety signals were observed. Pembrolizumab monotherapy did not significantly improve overall survival in similar patients that had received prior treatment in KEYNOTE-119. Conclusions: Atezolizumab plus nab-paclitaxel represents a potential new first-line standard of care for patients with metastatic PD-L1-positive TNBC. Other ICIs used as monotherapy, or combined with chemotherapy for advanced TNBC, as well as their use for earlier stage disease, are areas of ongoing investigation.
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Affiliation(s)
- Christine E Simmons
- Division of Medical Oncology, BC Cancer Agency-Vancouver, 600 West 10th Avenue, Vancouver, British Columbia, V5Z 4E6, Canada
| | | | - Joy McCarthy
- Dr H. Bliss Murphy Cancer Centre, St. John's, Newfoundland, Canada
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Choi J, Lee SY. Clinical Characteristics and Treatment of Immune-Related Adverse Events of Immune Checkpoint Inhibitors. Immune Netw 2020; 20:e9. [PMID: 32158597 PMCID: PMC7049586 DOI: 10.4110/in.2020.20.e9] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have been changing the paradigm of cancer treatment. However, immune-related adverse effects (irAEs) have also increased with the exponential increase in the use of ICIs. ICIs can break up the immunologic homeostasis and reduce T-cell tolerance. Therefore, inhibition of immune checkpoint can lead to the activation of autoreactive T-cells, resulting in various irAEs similar to autoimmune diseases. Gastrointestinal toxicity, endocrine toxicity, and dermatologic toxicity are common side effects. Neurotoxicity, cardiotoxicity, and pulmonary toxicity are relatively rare but can be fatal. ICI-related gastrointestinal toxicity, dermatologic toxicity, and hypophysitis are more common with anti- CTLA-4 agents. ICI-related pulmonary toxicity, thyroid dysfunction, and myasthenia gravis are more common with PD-1/PD-L1 inhibitors. Treatment with systemic steroids is the principal strategy against irAEs. The use of immune-modulatory agents should be considered in case of no response to the steroid therapy. Treatment under the supervision of multidisciplinary specialists is also essential, because the symptoms and treatments of irAEs could involve many organs. Thus, this review focuses on the mechanism, clinical presentation, incidence, and treatment of various irAEs.
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Affiliation(s)
- Juwhan Choi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea
| | - Sung Yong Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea
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Choi J, Lee SY. Clinical Characteristics and Treatment of Immune-Related Adverse Events of Immune Checkpoint Inhibitors. Immune Netw 2020. [PMID: 32158597 DOI: 10.4110/in.2020.20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have been changing the paradigm of cancer treatment. However, immune-related adverse effects (irAEs) have also increased with the exponential increase in the use of ICIs. ICIs can break up the immunologic homeostasis and reduce T-cell tolerance. Therefore, inhibition of immune checkpoint can lead to the activation of autoreactive T-cells, resulting in various irAEs similar to autoimmune diseases. Gastrointestinal toxicity, endocrine toxicity, and dermatologic toxicity are common side effects. Neurotoxicity, cardiotoxicity, and pulmonary toxicity are relatively rare but can be fatal. ICI-related gastrointestinal toxicity, dermatologic toxicity, and hypophysitis are more common with anti- CTLA-4 agents. ICI-related pulmonary toxicity, thyroid dysfunction, and myasthenia gravis are more common with PD-1/PD-L1 inhibitors. Treatment with systemic steroids is the principal strategy against irAEs. The use of immune-modulatory agents should be considered in case of no response to the steroid therapy. Treatment under the supervision of multidisciplinary specialists is also essential, because the symptoms and treatments of irAEs could involve many organs. Thus, this review focuses on the mechanism, clinical presentation, incidence, and treatment of various irAEs.
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Affiliation(s)
- Juwhan Choi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea
| | - Sung Yong Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea
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España S, Pérez Montes de Oca A, Marques-Pamies M, Cucurull M, Domenech M, Velarde JM, Salinas I, Moran T, Etxaniz O. Endocrine adverse events related to immune-oncology agents: retrospective experience of a single institution. Transl Lung Cancer Res 2020; 9:103-110. [PMID: 32206558 PMCID: PMC7082288 DOI: 10.21037/tlcr.2019.12.17] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Immune-oncology agents (IOA) represent a turning point in the treatment of several solid tumors (ST). Although their toxicity compares favorably with other treatments, IOA associate immune-related adverse events (IR-AE), among which endocrine-related AE stand out. We retrospectively evaluated the occurrence of endocrine (E) IR-AE in a cohort of patients with several ST treated with IOA. In addition, we assessed the correlation between likelihood of survival and the occurrence of IR-AE. Methods We collected data on clinical and molecular characteristics, efficacy and AE of 260 patients with ST treated with IOA from 2013 to 2017. We excluded patients with prior conditions or treatments potentially affecting thyroid test results. Results Lung cancer was the most prevalent diagnosis (70.2%). EIR-AE appeared in 18.1% of patients (total of 38 EIR-AE) and consisted of hypothyroidism, hyperthyroidism, pituitary disorders and type 1 diabetes mellitus in 60.5%, 21.1%, 15.8% and 2.6% of patients, respectively. EIR-AE were associated mainly to nivolumab, nivolumab plus ipilimumab (41.2% and 26.5%) and appeared after a median of 4.2 cycles of treatment. Specific therapy was required in 65.8% patients. There were significant differences in both progression-free survival (PFS) and overall survival (OS) for patients who experienced EIR-AE compared to those who did not [PFS: 56.7 (NC–NC) vs. 27.7 (14.3–41.3) months, P=0.008; OS: NC (NC–NC) vs. 31.4 (20.7–42.1) months, P=0.001]. Conclusions The incidence of EIR-AE in our study is similar to other series. Patients who develop EIR-AE might have a better prognosis compared to those who do not experience them.
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Affiliation(s)
- Sofia España
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | | | - Marc Cucurull
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marta Domenech
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Badalona-Applied Research Group in Oncology (B-ARGO), Fundació Institut Germans Trias i Pujol (IGTP), Badalona, Spain
| | | | - Isabel Salinas
- Endocrinology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Teresa Moran
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Badalona-Applied Research Group in Oncology (B-ARGO), Fundació Institut Germans Trias i Pujol (IGTP), Badalona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Olatz Etxaniz
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Badalona-Applied Research Group in Oncology (B-ARGO), Fundació Institut Germans Trias i Pujol (IGTP), Badalona, Spain
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Agrawal L, Bacal A, Jain S, Singh V, Emanuele N, Emanuele M, Meah F. Immune checkpoint inhibitors and endocrine side effects, a narrative review. Postgrad Med 2020; 132:206-214. [PMID: 31876444 DOI: 10.1080/00325481.2019.1709344] [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] [Indexed: 12/16/2022]
Abstract
Immune checkpoint inhibitors (ICPIs) are novel drugs in the field of oncology however carry the risk of immune-related dermatologic, gastrointestinal, and endocrine side effects which can be fatal. These new innovative immunoregulatory drugs have intertwined the fields of oncology and endocrinology. CTLA-4 and PD-1 are co-inhibitory receptors on T cells that turn the T cell 'off' when binding to receptors on APCs. Tumor cells can also carry receptors for CTLA- and PD-1. By rendering T cells inactive, tumor cells can evade immune attack. Antibodies that bind to CTLA-4 and PD-1 lead to T cell activation and destruction of both tumor and normal host cells. ICPIs have been used in a variety of malignancies including melanoma, kidney cancer, and non-small cell lung cancer. A unique underrecognized side effect of the autoimmune response is hypophysitis leading to central adrenal insufficiency which can be fatal. Additional immune-related adverse events (irAEs) include hypothyroidism, hyperthyroidism, diabetes, and hypoparathyroidism.
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Affiliation(s)
- L Agrawal
- Department of Endocrinology, Edward Hines Junior VA Hospital, Hines, IL, USA
| | - A Bacal
- Department of Endocrinology, Loyola University Medical Center, Maywood, IL, USA
| | - S Jain
- Department of Endocrinology, Loyola University Medical Center, Maywood, IL, USA
| | - V Singh
- Department of Endocrinology, Loyola University Medical Center, Maywood, IL, USA
| | - N Emanuele
- Department of Endocrinology, Edward Hines Junior VA Hospital, Hines, IL, USA
| | - Ma Emanuele
- Department of Endocrinology, Loyola University Medical Center, Maywood, IL, USA
| | - F Meah
- Department of Endocrinology, Edward Hines Junior VA Hospital, Hines, IL, USA
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Immune check point inhibitors-induced hypophysitis: a retrospective analysis of the French Pharmacovigilance database. Sci Rep 2019; 9:19419. [PMID: 31857638 PMCID: PMC6923385 DOI: 10.1038/s41598-019-56026-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/30/2019] [Indexed: 12/17/2022] Open
Abstract
Immune control point (ICI) inhibitors represent a significant advance in the management and survival of cancers such as melanoma or non-small cell bronchial carcinoma. However, they induce unusual side effects, such as hypophysitis, which are rarely described elsewhere. This nationwide retrospective study describes the characteristics of hypophysitis reported in the French pharmacovigilance database (FPVD). We requested for all cases of ICI-related hypophysitis registered in the FPVD before May 2018. An endocrinologist and a pharmacologist reviewed all cases. About 94 pituitary cases were selected, involving 49 females and 45 men. Ipilimumab alone or in combination was the most represented ICI (56%). Most cases (61%) were grade 3 severity and the majority (90%) were corticotropic deficiency cases. Cases with thyroid and/or gonadotropic involvement were 21% and 1% respectively. Five patients (8%) had panhypopituitarism. Pituitary MRI, when performed, was in favor of hypophysitis in 50%. No patient recovered his previous hormonal function. The mean time of onset was significantly shorter with ipilimumab than other ICIs. ICI-related hypophysitis generate deficits that do not spontaneously recover, even at a distance from the event, unlike thyroiditis. Patients must then benefit from long-term coordinated onco-endocrinological management, adapted to their own specific deficits.
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18
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Fessas P, Possamai LA, Clark J, Daniels E, Gudd C, Mullish BH, Alexander JL, Pinato DJ. Immunotoxicity from checkpoint inhibitor therapy: clinical features and underlying mechanisms. Immunology 2019; 159:167-177. [PMID: 31646612 DOI: 10.1111/imm.13141] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
Immune checkpoint inhibition with monoclonal antibodies is becoming increasingly commonplace in cancer medicine, having contributed to a widening of therapeutic options across oncological indications. Disruption of immune tolerance is the key mechanism of action of checkpoint inhibitors and although immune-related adverse events are a typical class effect of these compounds, the relationship between toxicity and response is not fully understood. Awareness and vigilance are paramount in recognizing potentially life-threatening toxicities and managing them in a timely manner. In this review article, we provide an overview of the clinical features, pathological findings and management principles of common immune-related toxicities, attempting to provide mechanistic insight into an increasingly common complication of cancer therapy.
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Affiliation(s)
- Petros Fessas
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Lucia A Possamai
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
| | - James Clark
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Ella Daniels
- National Centre for HIV Malignancy, Department of Oncology, Chelsea and Westminster Hospital, London, UK
| | - Cathrin Gudd
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
| | - Benjamin H Mullish
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
| | - James L Alexander
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
| | - David J Pinato
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK
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20
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Menz BD, Johnson JL, Gillard DF, Chong W, Ward MB. The Role of the Pharmacist in Optimizing Cancer Immunotherapy: A Retrospective Study of Nivolumab Adverse Events. J Pharm Pract 2019; 34:386-396. [PMID: 33969772 DOI: 10.1177/0897190019872937] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are an emerging treatment in cancer therapy for prolonging life, minimizing symptoms, and selectively targeting cancer. Program death 1 (PD-1) inhibitors, such as nivolumab, fall within this class, enabling the patient's immune system to detect and destroy cancer. The introduction of ICIs is changing cancer therapy, with new drugs and new toxicities-an evolving area encountered by pharmacists. OBJECTIVE This study aims to compare the pattern of nivolumab-induced adverse events observed in practice, when compared with clinical trial and literature data. The secondary aim of the study is to identify the presentation and treatment modalities initiated in practice. METHODS We performed a retrospective case note review across 2 South Australian hospitals to identify the common toxicities and symptomatic treatments experienced by patients receiving nivolumab. Results were compared with clinical trial data from product innovator Bristol-Myer Squib and other published literature. RESULTS Seventy patients were included in the study; of these, 60 (86%) experienced any grade adverse event(s). A total of 59 (84%) of 70 experienced mild to moderate grade 1 to grade 2 adverse events and 10 (14%) of 70 patients experienced severe grade 3 to grade 4 adverse events, displaying some consistencies with clinical trial and published literature data. Together, the prevalence of adverse events with details on presentation and treatments illustrates possible pharmacy practice strategies and areas for intervention. CONCLUSIONS The listed prevalence of adverse events and practice strategies identified throughout this study highlights how pharmacists may assist in the identification of predictable ICI toxicities associated with gastrointestinal, endocrine, dermatological toxicities, and fatigue.
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Affiliation(s)
- Bradley D Menz
- School of Pharmacy and Medical Sciences, 1067University of South Australia, North Terrace, Adelaide, South Australia, Australia.,375072Central Adelaide Local Health Network, Royal Adelaide Hospital, SA Pharmacy, North Terrace, Adelaide, South Australia, Australia.,6677Southern Adelaide Local Health Network, Flinders Medical Centre, SA Pharmacy, Bedford Park, South Australia, Australia
| | - Jacinta L Johnson
- School of Pharmacy and Medical Sciences, 1067University of South Australia, North Terrace, Adelaide, South Australia, Australia.,6677Southern Adelaide Local Health Network, Flinders Medical Centre, SA Pharmacy, Bedford Park, South Australia, Australia
| | - Davina F Gillard
- 375072Central Adelaide Local Health Network, Royal Adelaide Hospital, SA Pharmacy, North Terrace, Adelaide, South Australia, Australia
| | - William Chong
- 6677Southern Adelaide Local Health Network, Flinders Medical Centre, SA Pharmacy, Bedford Park, South Australia, Australia
| | - Michael B Ward
- School of Pharmacy and Medical Sciences, 1067University of South Australia, North Terrace, Adelaide, South Australia, Australia.,375072Central Adelaide Local Health Network, Royal Adelaide Hospital, SA Pharmacy, North Terrace, Adelaide, South Australia, Australia
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Castillero F, Castillo-Fernández O, Jiménez-Jiménez G, Fallas-Ramírez J, Peralta-Álvarez MP, Arrieta O. Cancer immunotherapy-associated hypophysitis. Future Oncol 2019; 15:3159-3169. [DOI: 10.2217/fon-2019-0101] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The advances in cancer therapy have included the development of drugs that inhibit immune checkpoint ligands. Two types of immune checkpoint inhibitors, both antibodies that target CTLA-4 and PD-1, have been approved for its use in NSCLC and melanoma as first-line or second-line therapy. Sadly, not desirable consequences of immunotherapy are immune-related adverse events. immune-related hypophysitis is the most common endocrine adverse event after thyroid disfunction. The particularity of endocrine immune-related adverse events is their non-reversibility, with incidence and prevalence destined to increase in the coming years, particularly if this form of therapy is used in the future for earlier stages of cancer. Therefore, hypophysitis represents a challenge for the physician, sometimes occurring without specific symptomatology and which should be considered for clinical management. In this review, we describe the current data regarding the pathophysiology and management for immune-related hypophysitis.
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Affiliation(s)
| | | | - Geiner Jiménez-Jiménez
- Oncology Department, Hospital Dr. Rafael Ángel Calderón Guardia, San José 10101, Costa Rica
| | - José Fallas-Ramírez
- Instituto de Investigaciones Farmacéuticas, Facultad de Farmacia, Universidad de Costa Rica, San José 11501, Costa Rica
| | - Marco P Peralta-Álvarez
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City 14080, México
- Laboratory of Personalized Medicine, Instituto Nacional de Cancerología (INCan), México City 14080, México
| | - Oscar Arrieta
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City 14080, México
- Laboratory of Personalized Medicine, Instituto Nacional de Cancerología (INCan), México City 14080, México
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22
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Chiloiro S, Capoluongo ED, Tartaglione T, Giampietro A, Bianchi A, Giustina A, Pontecorvi A, De Marinis L. The Changing Clinical Spectrum of Hypophysitis. Trends Endocrinol Metab 2019; 30:590-602. [PMID: 31345630 DOI: 10.1016/j.tem.2019.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/16/2019] [Accepted: 06/21/2019] [Indexed: 12/17/2022]
Abstract
Hypophysitis is a rare and potentially life-threatening disease, characterized by an elevated risk of complications, such as occurrence of acute central hypoadrenalism, persistent hypopituitarism, or extension of the inflammatory process to the neighboring neurological structures. In recent years, a large number of patients have been described as being affected by hypophysitis, due to the increased administration of immuno-chemotherapies. At the present time, the heterogeneous nature of hypophysitis diagnostic criteria and of the treatment protocols makes the management of affected patients difficult. We review the current data and evidence on primary and secondary hypophysitis, in order to suggest a diagnostic and therapeutic protocol that should be focused on a multidisciplinary approach, for reaching a prompt diagnosis and an appropriate and safe treatment.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Tommaso Tartaglione
- Department of Radiology, Istituto Dermopatico dell'Immacolata, Rome and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Giustina
- Department of Endocrinology, Università Vita Salute San Raffaele, Milan, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
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Yang J, He X, Lv Q, Jing J, Shi H. Management of Adverse Events in Cancer Patients Treated With PD-1/PD-L1 Blockade: Focus on Asian Populations. Front Pharmacol 2019; 10:726. [PMID: 31312140 PMCID: PMC6614522 DOI: 10.3389/fphar.2019.00726] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/05/2019] [Indexed: 02/05/2023] Open
Abstract
The interaction between programmed cell death protein 1 (PD-1) and its ligand programmed death-ligand 1 (PD-L1) induces exhaustions of cytotoxic lymphocytes in the tumor microenvironment, which facilitates tumor immune evasion. PD-1/PD-L1 blockade therapy, which prevents the receptors and ligands from binding to each other, disrupts the T-cell exhaustion signaling, thereby increasing antitumor immunity. Inspiringly, it has revolutionized the treatment of many different types of cancers including non-small-cell lung carcinoma, melanoma, lymphoma, and so on. However, with the intention of generating an antitumor immune response, PD-1/PD-L1 blockade may also lead to a spectrum of side effects. The profile of adverse events (AEs) of PD-1/PD-L1 blockade is not exactly the same with other immune checkpoint blockades, such as blockade of cytotoxic T-lymphocyte-associated protein 4. Although cutaneous, gastrointestinal, and pulmonary systems are common victims, AEs of PD-1/PD-L1 blockade might occur in any other organ system of the human body. These toxicities can be life-threatening if not managed promptly, and proper treatment intervention is imperative for optimal control and prevention of severe damage. Currently, clinical practice for the management of AEs in PD-1/PD-L1 blockade remains sporadic and variable. The majority of initial clinical trials were carried out in Caucasians. The trials of multiple races usually included a small portion of Asian participants, and results were calculated and interpreted for the entire included subjects without any race-specific conclusions. Therefore, the information on PD-1/PD-L1 blockade in Asians is far from systematic or comprehensive. Recently, as the results of clinical trials of anti-PD-1/PD-L1 agents in Asian populations have been gradually released, we summarized current evidence with a specific focus on the Asian population, hoping to outline strategies and offer guidance on the management of AEs in cancer patients treated with PD-1/PD-L1 blockade in the Asian world.
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Affiliation(s)
- Jiqiao Yang
- Laboratory of Tumor Targeted and Immune Therapy, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.,Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.,Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiujing He
- Laboratory of Tumor Targeted and Immune Therapy, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.,Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Lv
- Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.,Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Jing
- Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Hubing Shi
- Laboratory of Tumor Targeted and Immune Therapy, Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.,Clinical Research Center for Breast, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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O'Reilly A, Hughes P, Mann J, Lai Z, Teh JJ, Mclean E, Edmonds K, Lingard K, Chauhan D, Lynch J, Au L, Ludlow A, Pattison N, Wiseman T, Turajlic S, Gore M, Larkin J, Husson O. An immunotherapy survivor population: health-related quality of life and toxicity in patients with metastatic melanoma treated with immune checkpoint inhibitors. Support Care Cancer 2019; 28:561-570. [PMID: 31089820 PMCID: PMC6954131 DOI: 10.1007/s00520-019-04818-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/16/2019] [Indexed: 02/08/2023]
Abstract
Purpose The immune checkpoint inhibitors (ICIs) have resulted in subgroups of patients with metastatic melanoma achieving high-quality durable responses. Metastatic melanoma survivors are a new population in the era of cancer survivorship. The aim of this study was to evaluate metastatic melanoma survivors in terms of health-related quality of life (HRQoL), immune-related adverse events (irAEs) and exposure to immunosuppressive agents in a large single centre in the UK. Methods We defined the survivor population as patients with a diagnosis of metastatic melanoma who achieved a durable response to an ICI and had been followed-up for a minimum of 12 months from initiation of ICI without disease progression. HRQoL was assessed using SF-36. Electronic health records were accessed to collect data on demographics, treatments, irAEs and survival. HRQoL data was compared with two norm-based datasets. Results Eighty-four metastatic melanoma survivors were eligible and 87% (N = 73) completed the SF-36. ICI-related toxicity of any grade occurred in 92% of patients and 43% had experienced a grade 3 or 4 toxicity. Almost half (49%) of the patients required steroids for the treatment of ICI-related toxicity, whilst 14% required treatment with an immunosuppressive agent beyond steroids. Melanoma survivors had statistically significant lower HRQoL scores with regard to physical, social and physical role functioning and general health compared with the normative population. There was a trend towards inferior scores in patients with previous exposure to ipilimumab compared with those never exposed to ipilimumab. Conclusions Our results show that metastatic melanoma survivors have potentially experienced significant ICI-related toxicity and experience significant impairments in specific HRQoL domains. Future service planning is required to meet this population’s unique survivorship needs. Electronic supplementary material The online version of this article (10.1007/s00520-019-04818-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aine O'Reilly
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Peta Hughes
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Jasmine Mann
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | | | | | | | - Kim Edmonds
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Karla Lingard
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Dharmisha Chauhan
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Joanna Lynch
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Lewis Au
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Aileen Ludlow
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Natalie Pattison
- University of Hertfordshire/East & North Herts NHS Trust, London, UK
| | - Theresa Wiseman
- Health Service Research, Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Samra Turajlic
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK.,Translational Cancer Therapeutics Laboratory, The Francis Crick Institute, London, UK
| | - Martin Gore
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - James Larkin
- Renal and Skin Units, The Royal Marsden Hospital National Health Service Foundation Trust, London, UK
| | - Olga Husson
- Division of Clinical Studies, Institute of Cancer Research, London, UK.
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Castinetti F, Albarel F, Archambeaud F, Bertherat J, Bouillet B, Buffier P, Briet C, Cariou B, Caron P, Chabre O, Chanson P, Cortet C, Do Cao C, Drui D, Haissaguerre M, Hescot S, Illouz F, Kuhn E, Lahlou N, Merlen E, Raverot V, Smati S, Verges B, Borson-Chazot F. French Endocrine Society Guidance on endocrine side effects of immunotherapy. Endocr Relat Cancer 2019; 26:G1-G18. [PMID: 30400055 PMCID: PMC6347286 DOI: 10.1530/erc-18-0320] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 10/08/2018] [Indexed: 12/14/2022]
Abstract
The management of cancer patients has changed due to the considerably more frequent use of immune checkpoint inhibitors (ICPIs). However, the use of ICPI has a risk of side effects, particularly endocrine toxicity. Since the indications for ICPI are constantly expanding due to their efficacy, it is important that endocrinologists and oncologists know how to look for this type of toxicity and how to treat it when it arises. In view of this, the French Endocrine Society initiated the formulation of a consensus document on ICPI-related endocrine toxicity. In this paper, we will introduce data on the general pathophysiology of endocrine toxicity, and we will then outline expert opinion focusing primarily on methods for screening, management and monitoring for endocrine side effects in patients treated by ICPI. We will then look in turn at endocrinopathies that are induced by ICPI including dysthyroidism, hypophysitis, primary adrenal insufficiency and fulminant diabetes. In each chapter, expert opinion will be given on the diagnosis, management and monitoring for each complication. These expert opinions will also discuss the methodology for categorizing these side effects in oncology using 'common terminology criteria for adverse events' (CTCAE) and the difficulties in applying this to endocrine side effects in the case of these anti-cancer therapies. This is shown in particular by certain recommendations that are used for other side effects (high-dose corticosteroids, contraindicated in ICPI for example) and that cannot be considered as appropriate in the management of endocrine toxicity, as it usually does not require ICPI withdrawal or high-dose glucocorticoid intake.
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Affiliation(s)
- F Castinetti
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Marseille Medical Genetics (MMG), and Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille (AP-HM), Hôpital de la Conception, Centre de Référence des Maladies Rares de l’Hypophyse HYPO, Marseille, France
- Correspondence should be addressed to F Castinetti:
| | - F Albarel
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Marseille Medical Genetics (MMG), and Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille (AP-HM), Hôpital de la Conception, Centre de Référence des Maladies Rares de l’Hypophyse HYPO, Marseille, France
| | - F Archambeaud
- Service de Médecine Interne B – Endocrinologie, Limoges Cedex, France
| | - J Bertherat
- Hôpital Cochin, Service d’Endocrinologie et Maladies Métaboliques, Paris Cedex 14, France
| | - B Bouillet
- CHU Dijon, Hôpital François Mitterrand, Service d’Endocrinologie, Diabétologie, Maladies Métaboliques, Dijon Cedex, France
- Unité INSERM LNC-UMR 1231, Université de Bourgogne, Dijon, France
| | - P Buffier
- CHU Dijon, Hôpital François Mitterrand, Service d’Endocrinologie, Diabétologie, Maladies Métaboliques, Dijon Cedex, France
| | - C Briet
- Institut MITOVASC, INSERM U1083, Angers University, Department of Endocrinology, Diabetology and Nutrition, University Medical Center, Angers, France
| | - B Cariou
- Department of Endocrinology, L’Institut du Thorax, CHU Nantes, Nantes, France
| | - Ph Caron
- CHU de Toulouse – Hôpital Larrey – Service d’Endocrinologie – Maladies métaboliques – Nutrition, TSA 30030, Toulouse Cedex 9, France
| | - O Chabre
- CHU de Grenoble – Hôpital Albert Michallon, Service d’Endocrinologie-Diabétologie-Nutrition, Grenoble Cedex 9, France
| | - Ph Chanson
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, et UMR S-1185 Faculté de Médecine Paris-Sud, University of Paris-Saclay, Le Kremlin-Bicêtre, France
| | - C Cortet
- CHRU de Lille – Hopital Huriez, Service d’Endocrinologie, Lille Cedex, France
| | - C Do Cao
- CHRU de Lille – Hopital Huriez, Service d’Endocrinologie, Lille Cedex, France
| | - D Drui
- Department of Endocrinology, L’Institut du Thorax, CHU Nantes, Nantes, France
| | - M Haissaguerre
- CHU de Bordeaux – Hôpital du Haut Lévêque, Service d’Endocrinologie-Diabétologie et Maladies Métaboliques, Pessac Cedex, France
| | - S Hescot
- Institut Curie, Oncologie Endocrinienne, Saint Cloud, France
| | - F Illouz
- Department of Endocrinology, Diabetes and Nutrition, Reference Centre of Rare Thyroid Disease, Hospital of Angers, Angers Cedex 09, France
| | - E Kuhn
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, et UMR S-1185 Faculté de Médecine Paris-Sud, University of Paris-Saclay, Le Kremlin-Bicêtre, France
| | - N Lahlou
- Département d’Hormonologie Spécialisée, BPR-AS, Pannes, France
| | - E Merlen
- CHRU de Lille – Hopital Huriez, Service d’Endocrinologie, Lille Cedex, France
| | - V Raverot
- Hospices Civils de Lyon, Laboratoire d’Hormonologie, Service de Biochimie et Biologie Moléculaire, Groupement Hospitalier Est, Lyon, France
| | - S Smati
- Department of Endocrinology, L’Institut du Thorax, CHU Nantes, Nantes, France
| | - B Verges
- CHU Dijon, Hôpital François Mitterrand, Service d’Endocrinologie, Diabétologie, Maladies Métaboliques, Dijon Cedex, France
- Unité INSERM LNC-UMR 1231, Université de Bourgogne, Dijon, France
| | - F Borson-Chazot
- Hospices Civils de Lyon, Fédération d’Endocrinologie, Université Claude Bernard Lyon 1, Lyon, France
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26
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Tan MH, Iyengar R, Mizokami-Stout K, Yentz S, MacEachern MP, Shen LY, Redman B, Gianchandani R. Spectrum of immune checkpoint inhibitors-induced endocrinopathies in cancer patients: a scoping review of case reports. Clin Diabetes Endocrinol 2019; 5:1. [PMID: 30693099 PMCID: PMC6343255 DOI: 10.1186/s40842-018-0073-4] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Since 2011 six immune checkpoint inhibitors (ICI) have been approved to treat patients with many advanced solid tumor and hematological malignancies to improve their prognosis. Case reports of their endocrine immune-related adverse events [irAEs]) are increasingly published as more real-world patients with these malignancies are treated with these drugs. They alert physicians of a drug's AEs (which may change during a drug's life cycle) and contribute to post-marketing safety surveillance. Using a modified framework of Arksey and O'Malley, we conducted a scoping review of the spectrum and characteristics of ICI-induced endocrinopathies case reports before and after ICIs are marketed. METHODS In July 2017, we searched, without date and language restrictions, 4 citation databases for ICI-induced endocrinopathies. We also hand-searched articles' references, contents of relevant journals, and ran supplemental searches to capture recent reports through January 2018. For this study, a case should have information on type of cancer, type of ICI, clinical presentation, biochemical tests, treatment plus temporal association of ICI initiation with endocrinopathies. Two endocrinologists independently extracted the data which were then summarized and categorized. RESULTS One hundred seventy nine articles reported 451 cases of ICI-induced endocrinopathies - 222 hypopituitarism, 152 thyroid disorders, 66 diabetes mellitus, 6 primary adrenal insufficiencies, 1 ACTH-dependent Cushing's syndrome, 1 hypoparathyroidism and 3 diabetes insipidus cases. Their clinical presentations reflect hormone excess or deficiency. Some were asymptomatic and others life-threatening. One or more endocrine glands could be affected. Polyglandular endocrinopathies could present simultaneously or in sequence. Many occur within 5 months of therapy initiation; a few occurred after ICI was stopped. Mostly irreversible, they required long-term hormone replacement. High dose steroids were used when non-endocrine AEs coexisted or as therapy in adrenal insufficiency. There was variability of information in the case reports but all met the study criteria to make a diagnosis. CONCLUSIONS The spectrum of ICI-induced endocrinopathies is wide (5 glands affected) and their presentation varied (12 endocrinopathies). Clinical reasoning integrating clinical, biochemical and treatment information is needed to properly diagnose and manage them. Physicians should be vigilant for their occurrence and be able to diagnose, investigate and manage them appropriately at onset and follow-up.
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Affiliation(s)
- Meng H. Tan
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Ravi Iyengar
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
- Present address: Endocrinology, Rush University Medical Center, 1725 West Harrison Street, Chicago, IL 60612 USA
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Sarah Yentz
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Mark P. MacEachern
- Taubman Health Sciences Library, University of Michigan, 1135 Catherine Street, Ann Arbor, MI 48109 USA
| | - Li Yan Shen
- Affiliated Hospital of QingDao University, QingDao, 16 Jiangsu Road, Sinan Qu, Qingdao, Shi, Shandong Sheng China
| | - Bruce Redman
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Roma Gianchandani
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
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27
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Pai CCS, Simons DM, Lu X, Evans M, Wei J, Wang YH, Chen M, Huang J, Park C, Chang A, Wang J, Westmoreland S, Beam C, Banach D, Bowley D, Dong F, Seagal J, Ritacco W, Richardson PL, Mitra S, Lynch G, Bousquet P, Mankovich J, Kingsbury G, Fong L. Tumor-conditional anti-CTLA4 uncouples antitumor efficacy from immunotherapy-related toxicity. J Clin Invest 2018; 129:349-363. [PMID: 30530991 DOI: 10.1172/jci123391] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/24/2018] [Indexed: 12/11/2022] Open
Abstract
While immune checkpoint blockade leads to potent antitumor efficacy, it also leads to immune-related adverse events in cancer patients. These toxicities stem from systemic immune activation resulting in inflammation of multiple organs, including the gastrointestinal tract, lung, and endocrine organs. We developed a dual variable domain immunoglobulin of anti-CTLA4 antibody (anti-CTLA4 DVD, where CTLA4 is defined as cytotoxic T lymphocyte-associated antigen-4) possessing an outer tumor-specific antigen-binding site engineered to shield the inner anti-CTLA4-binding domain. Upon reaching the tumor, the outer domain was cleaved by membrane type-serine protease 1 (MT-SP1) present in the tumor microenvironment, leading to enhanced localization of CTLA4 blockade. Anti-CTLA4 DVD markedly reduced multiorgan immune toxicity by preserving tissue-resident Tregs in Rag 1-/- mice that received naive donor CD4+ T cells from WT C57BL/6j mice. Moreover, anti-CTLA4 DVD induced potent antitumor effects by decreasing tumor-infiltrating Tregs and increasing the infiltration of antigen-specific CD8+ T lymphocytes in TRAMP-C2-bearing C57BL/6j mice. Treg depletion was mediated through the antibody-dependent cellular cytotoxicity (ADCC) mechanism, as anti-CTLA4 without the FcγR-binding portion (anti-CTLA4 DANA) spared Tregs, preventing treatment-induced toxicities. In summary, our results demonstrate an approach to anti-CTLA4 blockade that depletes tumor-infiltrating, but not tissue-resident, Tregs, preserving antitumor effects while minimizing toxicity. Thus, our tumor-conditional anti-CTLA4 DVD provides an avenue for uncoupling antitumor efficacy from immunotherapy-induced toxicities.
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Affiliation(s)
- Chien-Chun Steven Pai
- Department of Hematology and Oncology, School of Medicine, UCSF, San Francisco, California, USA
| | | | - Xiaoqing Lu
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | - Michael Evans
- Department of Radiology and Biomedical Imaging, School of Medicine, UCSF, San Francisco, California, USA
| | - Junnian Wei
- Department of Radiology and Biomedical Imaging, School of Medicine, UCSF, San Francisco, California, USA
| | - Yung-Hua Wang
- Department of Radiology and Biomedical Imaging, School of Medicine, UCSF, San Francisco, California, USA
| | - Mingyi Chen
- Department of Hematopathology, School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John Huang
- Department of Hematology and Oncology, School of Medicine, UCSF, San Francisco, California, USA
| | - Chanhyuk Park
- Department of Hematology and Oncology, School of Medicine, UCSF, San Francisco, California, USA
| | - Anthony Chang
- Department of Hematology and Oncology, School of Medicine, UCSF, San Francisco, California, USA
| | - Jiaxi Wang
- Department of Hematology and Oncology, School of Medicine, UCSF, San Francisco, California, USA
| | | | - Christine Beam
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | - Dave Banach
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | - Diana Bowley
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | - Feng Dong
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | - Jane Seagal
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | - Wendy Ritacco
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | | | - Soumya Mitra
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | - Grace Lynch
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | - Pete Bousquet
- AbbVie Bioresearch Center, Worcester, Massachusetts, USA
| | | | | | - Lawrence Fong
- Department of Hematology and Oncology, School of Medicine, UCSF, San Francisco, California, USA.,Parker Immunotherapy Institute, Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, California, USA
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28
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Garon-Czmil J, Petitpain N, Rouby F, Sassier M, Babai S, Yelehe-Okouma M, Weryha G, Klein M, Gillet P. Thyroiditis and immune check point inhibitors: the post-marketing experience using the French National Pharmacovigilance database. Fundam Clin Pharmacol 2018; 33:241-249. [PMID: 30308083 DOI: 10.1111/fcp.12423] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 09/07/2018] [Accepted: 10/05/2018] [Indexed: 12/20/2022]
Abstract
Immunotherapy with immune checkpoint inhibitors (ICIs) for cancer has become increasingly prescribed in recent years. Indeed, it is used to treat both solid and hematological malignancies due to their considerable potential in treating melanoma, non-small cell lung and other cancers. Immune-mediated related adverse endocrine toxicity, and especially thyroiditis, is seen as a growing problem needing specific screening and management. This study aims at describing thyroid dysfunctions induced by the ICIs marketed in France, which are registered in the French Pharmacovigilance database. This database was queried for nivolumab, pembrolizumab, and ipilimumab-induced adverse drug reactions reported before April 30, 2017. Both a pharmacologist and an endocrinologist have reviewed each case to select only those of peripheral thyroiditis (thyrotoxicosis and hypothyroidism). During this period, 110 thyroiditis following ICI therapy were reported. Sex/ratio was around one. Most of the cases (47.2%) were asymptomatic. Although some thyrotoxicosis cases were severe, no orbitopathy was reported. Hypothyroidism and thyrotoxicosis were equally described. Antithyroid antibodies were positive in only 16% patients. The ultrasonography was informative in 19% patients. Levothyroxine supplementation was necessary in 57% patients, leading to 19% recovery. With a dedicated optimized management, most of the cases did not require immunotherapy discontinuation. Finally, immune-mediated related thyroiditis is increasing due to a wider prescription of ICI therapy in various cancer conditions and systematic screening. Often asymptomatic, they lead to a local activation accompanied by hormonal deficiency in the long run. It is necessary to carry out an early and sustained multidisciplinary screening to allow immunotherapy continuation.
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Affiliation(s)
- Julie Garon-Czmil
- Department of Clinical Pharmacology and Pharmacovigilance, University Hospital of Nancy, 29 avenue du Maréchal de Lattre de Tassigny, Nancy, 54035, France.,Department of Endocrinology and Medical Gynecology, University Hospital of Nancy, Rue du Morvan, Vandœuvre-lès-Nancy, 54500, France
| | - Nadine Petitpain
- Department of Clinical Pharmacology and Pharmacovigilance, University Hospital of Nancy, 29 avenue du Maréchal de Lattre de Tassigny, Nancy, 54035, France
| | - Franck Rouby
- Department of Clinical Pharmacology and Pharmacovigilance, University Hospital of Marseille, 270 Boulevard Sainte Marguerite, Marseille, 13009, France
| | - Marion Sassier
- Department of Pharmacology, University Hospital of Caen, Avenue de la Côte de Nacre, Caen, 14000, France
| | - Samy Babai
- Department of Pharmacovigilance, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris, University Hospital of Creteil, 51, avenue du Maréchal de Lattre de Tassigny, CRETEIL CEDEX, 94010, France
| | - Melissa Yelehe-Okouma
- Department of Clinical Pharmacology and Pharmacovigilance, University Hospital of Nancy, 29 avenue du Maréchal de Lattre de Tassigny, Nancy, 54035, France
| | - Georges Weryha
- Department of Endocrinology and Medical Gynecology, University Hospital of Nancy, Rue du Morvan, Vandœuvre-lès-Nancy, 54500, France
| | - Marc Klein
- Department of Endocrinology and Medical Gynecology, University Hospital of Nancy, Rue du Morvan, Vandœuvre-lès-Nancy, 54500, France
| | - Pierre Gillet
- Department of Clinical Pharmacology and Pharmacovigilance, University Hospital of Nancy, 29 avenue du Maréchal de Lattre de Tassigny, Nancy, 54035, France.,UMR 7365 CNRS-UL, IMoPA, Biopôle de l'Université de Lorraine, Campus Brabois-Santé, 9 Avenue de la Forêt de Haye, BP 20199, Vandœuvre-lès-Nancy, 54505, France
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29
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Myers G. Immune-related adverse events of immune checkpoint inhibitors: a brief review. ACTA ACUST UNITED AC 2018; 25:342-347. [PMID: 30464684 DOI: 10.3747/co.25.4235] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors (icis) such as inhibitors of ctla-4, PD-1, and PD-L1, given as monotherapy or combination therapy have emerged as effective treatment options for immune-sensitive solid tumours and hematologic malignancies. The benefits of icis can be offset by immune-related adverse events (iraes) that leave all organ systems vulnerable and subsequently increase the risk for morbidity and mortality. Because of fluctuating onset and prolonged duration, the toxicities associated with iraes represent a shift from the understanding of conventional anticancer toxicities. The ctla-4 and PD-1/PD-L1 inhibitors modulate T-cell response differently, resulting in distinct toxicity patterns, toxicity kinetics, and dose-toxicity relationships. Using individualized patient education, screening, and assessment for the early identification of iraes is key to proactive management and is therefore key to improving outcomes and prolonging therapy. Management of iraes is guided by appropriate grading, which sets the stage for the treatment setting (outpatient vs. inpatient), ici treatment course (delay vs. discontinuation), supportive care, corticosteroid use, organ specialist consultation, and additional immunosuppression. Health care professionals in oncology must work collaboratively with emergency and community colleagues to facilitate an understanding of iraes in an effort to optimize seamless care.
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Affiliation(s)
- G Myers
- Department of Pharmacy, Horizon Health Network-The Moncton Hospital, Moncton, NB, and Canadian Association of Pharmacy in Oncology, Vancouver, BC
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30
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Illouz F, Drui D, Caron P, Do Cao C. Expert opinion on thyroid complications in immunotherapy. ANNALES D'ENDOCRINOLOGIE 2018; 79:555-561. [PMID: 30126627 DOI: 10.1016/j.ando.2018.07.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Thyroid pathologies are the most common forms of endocrinopathy under anticancer immunotherapy. Frequency ranges from 3% to 22% for hypothyroidism and 1% to 11% for thyrotoxicosis. Risk is higher with anti-PD-1 than anti-CTLA-4 treatment and higher again with associated treatment. Pathophysiology mainly consists in silent inflammatory thyroiditis, which accounts for the usual presentation of transient thyrotoxicosis followed by hypothyroidism. Therapeutic strategy usually consists in monitoring with or without symptomatic treatment in case of thyrotoxicosis, and levothyroxine replacement therapy in case of symptomatic hypothyroidism or TSH>10 mIU/L. Screening for dysthyroidism should be systematic ahead of treatment and before each immunotherapy injection for the first 6 months, then at a lower rhythm. It comprises clinical assessment and TSH assay. Onset of thyroid dysfunction should not interrupt immunotherapy, being mainly transient, easy to treat and mild. Teamwork between oncologists and endocrinologists improves screening and management, so as better to accompany the patient during treatment.
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Affiliation(s)
- Frederic Illouz
- Department of Endocrinology, Diabetes and Nutrition, Reference Centre of Rare Thyroid and Hormonal Receptors Disease, Hospital of Angers, 49933 Angers cedex 09, France.
| | - Delphine Drui
- Department of Endocrinology, Institut du Thorax, CHU de Nantes, 44000 Nantes, France
| | - Philippe Caron
- Service d'Endocrinologie, Maladies Métaboliques, Nutrition, CHU de Toulouse, Hôpital Larrey, TSA 30030, 31059 Toulouse cedex 9, France
| | - Christine Do Cao
- Service d'Endocrinologie, CHRU de Lille, Hôpital Huriez, 59037 Lille cedex, France
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31
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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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32
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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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