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Rao Ullur A, Côté G, Pelletier K, Kitchlu A. Immunotherapy in oncology and the kidneys: a clinical review of the evaluation and management of kidney immune-related adverse events. Clin Kidney J 2023; 16:939-951. [PMID: 37261008 PMCID: PMC10229281 DOI: 10.1093/ckj/sfad014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Indexed: 11/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICI) are now widely used in the treatment of many cancers, and currently represent the standard of care for multiple malignancies. These agents enhance the T cell immune response to target cancer tissues, and have demonstrated considerable benefits for cancer outcomes. However, despite these improved outcomes, there are important kidney immune-related adverse events (iRAEs) associated with ICI. Acute tubulo-interstitial nephritis remains the most frequent kidney iRAE, however glomerular lesions and electrolytes disturbances are increasingly being recognized and reported. In this review, we summarize clinical features and identify risk factors for kidney iRAEs, and discuss the current understanding of pathophysiologic mechanisms. We highlight the evidence basis for guideline-recommended management of ICI-related kidney injury as well as gaps in current knowledge. We advocate for judicious use of kidney biopsy to identify ICI-associated kidney injury, and early use of corticosteroid treatment where appropriate. Selected patients may also be candidates for re-challenge with ICI therapy after a kidney iRAE, in view of current data on recurrent rates of kidney injury. Risk of benefits of re-challenge must be considered on an individual considering patient preferences and prognosis. Lastly, we review current knowledge of ICI use in the setting of patients with end-stage kidney disease, including kidney transplant recipients and those receiving dialysis, which suggest that these patients should not be summarily excluded from the potential benefits of these cancer therapies.
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Affiliation(s)
- Avinash Rao Ullur
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Gabrielle Côté
- Division of Nephrology, Department of Medicine, CHU de Québec, Université Laval, Quebec City, Canada
| | - Karyne Pelletier
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
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2
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Miao J, Sise ME, Herrmann SM. Immune checkpoint inhibitor related nephrotoxicity: Advances in clinicopathologic features, noninvasive approaches, and therapeutic strategy and rechallenge. FRONTIERS IN NEPHROLOGY 2022; 2:1017921. [PMID: 37674988 PMCID: PMC10479679 DOI: 10.3389/fneph.2022.1017921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/28/2022] [Indexed: 09/08/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are used increasingly to treat more than 17 cancers and have shown promising therapeutic results. However, ICI use can result in a variety of immune-related adverse events (IRAEs) which can occur in any organ, including the kidneys. Acute kidney injury (AKI) is the most common nephrotoxicity, classically related to acute interstitial nephritis. Much more diverse patterns and presentations of ICI-related kidney injury can occur, and have implications for diagnostic and therapeutic management approaches. In this review, we summarize the recently approved ICIs for cancer, the incidence and risk factors for nephrotoxicity, our current understanding of the pathophysiological mechanisms and the key clinicopathological features of ICI-related AKI, and therapeutic strategies. We also explore important knowledge that require further investigation, such as the risks/benefits of ICI rechallenge in patients who recover from an episode of ICI-related AKI, and the application of liquid biopsy and microbiome to identify noninvasive biomarkers to diagnose and predict kidney injury and guide ICI therapy.
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Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Meghan E. Sise
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, United States
| | - Sandra M. Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
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3
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Thomas J, Jain A, Chong H. Lymphocytic Hypophysitis in a Patient With Suspected Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). Cureus 2022; 14:e30178. [PMID: 36397915 PMCID: PMC9648682 DOI: 10.7759/cureus.30178] [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: 08/22/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
Abstract
Lymphocytic hypophysitis (LH) is a rare, autoimmune condition that presents with a range of symptoms that must garner the attention of medical practitioners. Clinically, it is characterized by symptoms of a compressive sellar mass with varying degrees of hypopituitarism due to chronic inflammatory infiltrate of the pituitary gland. It is often seen in women in their third trimester or postpartum and is associated with other autoimmune phenomena. Our case report describes a 73-year-old female with a past medical history of hypothyroidism and hypertension, who presented with continued intermittent dizziness, fatigue, and mild subjective hearing loss for the past several months. She was referred to the emergency department due to a sodium level of 119 and was initially diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient was treated accordingly; however, she failed to show signs of improvement. Due to her clinical presentation, imaging studies, and laboratory results, the patient was suspected to have LH, which was confirmed with the improvement of her symptoms after treatment with steroids. Because of the rare occurrence and possible atypical presentation of LH, this case illustrates the importance of maintaining a high index of clinical suspicion when diagnosing a patient with an unknown cause of hyponatremia, especially in patients with coexisting autoimmune disorders.
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4
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Yeh H, Chiang CC, Yen TH. Hepatocellular carcinoma in patients with renal dysfunction: Pathophysiology, prognosis, and treatment challenges. World J Gastroenterol 2021; 27:4104-4142. [PMID: 34326614 PMCID: PMC8311541 DOI: 10.3748/wjg.v27.i26.4104] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/17/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
The population of patients with hepatocellular carcinoma (HCC) overlaps to a high degree with those for chronic kidney disease (CKD) and end-stage renal disease (ESRD). The degrees of renal dysfunction vary, from the various stages of CKD to dialysis-dependent ESRD, which often affects the prognosis and treatment choice of patients with HCC. In addition, renal dysfunction makes treatment more difficult and may negatively affect treatment outcomes. This study summarized the possible causes of the high comorbidity of HCC and renal dysfunction. The possible mechanisms of CKD causing HCC involve uremia itself, long-term dialysis status, immunosuppressive agents for postrenal transplant status, and miscellaneous factors such as hormone alterations and dysbiosis. The possible mechanisms of HCC affecting renal function include direct tumor invasion and hepatorenal syndrome. Finally, we categorized the risk factors that could lead to both HCC and CKD into four categories: Environmental toxins, viral hepatitis, metabolic syndrome, and vasoactive factors. Both CKD and ESRD have been reported to negatively affect HCC prognosis, but more research is warranted to confirm this. Furthermore, ESRD status itself ought not to prevent patients receiving aggressive treatments. This study then adopted the well-known Barcelona Clinic Liver Cancer guidelines as a framework to discuss the indicators for each stage of HCC treatment, treatment-related adverse renal effects, and concerns that are specific to patients with pre-existing renal dysfunction when undergoing aggressive treatments against CKD and ESRD. Such aggressive treatments include liver resection, simultaneous liver kidney transplantation, radiofrequency ablation, and transarterial chemoembolization. Finally, focusing on patients unable to receive active treatment, this study compiled information on the latest systemic pharmacological therapies, including targeted and immunotherapeutic drugs. Based on available clinical studies and Food and Drug Administration labels, this study details the drug indications, side effects, and dose adjustments for patients with renal dysfunction. It also provides a comprehensive review of information on HCC patients with renal dysfunction from disease onset to treatment.
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Affiliation(s)
- Hsuan Yeh
- Department of Nephrology, Chang Gung Memorial Hospital and Chang Gung University, Taipei 105, Taiwan
| | - Chun-Cheng Chiang
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Chang Gung Memorial Hospital and Chang Gung University, Taipei 105, Taiwan
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5
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Goyal I, Pandey MR, Sharma R, Chaudhuri A, Dandona P. The side effects of immune checkpoint inhibitor therapy on the endocrine system. Indian J Med Res 2021; 154:559-570. [PMID: 35435341 PMCID: PMC9205006 DOI: 10.4103/ijmr.ijmr_313_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a relatively newer class of drugs approved for the treatment of malignancies such as melanoma, renal, bladder and lung cancer. Immune-related adverse events (IrAEs) involving the endocrine system are a common side effect of these drugs. The spectrum of endocrine adverse events varies by the drug class. Cytotoxic T-lymphocyte–associated antigen-4 inhibitors commonly cause hypophysitis/hypopituitarism, whereas the incidence of thyroid disease is higher with programmed cell death (PD)-1/ ligand (PD-L) protein 1 inhibitors. The focus of this review is to describe the individual endocrinopathies with their possible mechanisms, signs and symptoms, clinical assessment and disease management. Multiple mechanisms of IrAEs have been described in literature including type II/IV hypersensitivity reactions and development of autoantibodies. Patients with pre-existing autoimmune endocrine diseases can have disease exacerbation following ICI therapy rather than de novo IrAEs. Most of the endocrinopathies are relatively mild, and timely hormone replacement therapy allows continuation of ICIs. However, involvement of the pituitary–adrenal axis could be life-threatening if not recognized. Corticosteroids are helpful when the pituitary–adrenal axis is involved. In cases of severe endocrine toxicity (grade 3/4), ICIs should be temporarily discontinued and can be restarted after adequate hormonal therapy. Endocrinologists and general internists need to be vigilant and maintain a high degree of awareness for these adverse events.
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Affiliation(s)
- Itivrita Goyal
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
| | - Manu Raj Pandey
- Department of Hematology & Oncology, State University of New York at Buffalo; Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Rajeev Sharma
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo; Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Ajay Chaudhuri
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
| | - Paresh Dandona
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
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6
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George AS, Fernandez CJ, Eapen D, Pappachan JM. Organ-specific Adverse Events of Immune Checkpoint Inhibitor Therapy, with Special Reference to Endocrinopathies. TOUCHREVIEWS IN ENDOCRINOLOGY 2021; 17:21-32. [PMID: 35118443 PMCID: PMC8320015 DOI: 10.17925/ee.2021.17.1.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/09/2021] [Indexed: 02/05/2023]
Abstract
Immune checkpoint inhibitors are potent and promising immunotherapeutic agents that are increasingly used for the management of various types of advanced cancers. The widespread approval of this group of drugs simultaneously revealed immune-related adverse events as unique side-effects. Endocrinopathies are one of the most common immune-related adverse events. The precise pathogenic mechanisms for these endocrinopathies are still unclear. Though few of the endocrinopathies are reversible, calling for only symptom control, most are irreversible, requiring multiple long-term hormone replacement therapies. However, in contrast to other organ-specific immune-related adverse events, patients with endocrinopathies can continue their immune checkpoint therapy, provided the hormone replacement therapy is adequate and the symptoms are controlled. Though patients who have developed immune-related adverse events demonstrate superior antitumor activity and overall survival, due to the high morbidity associated with the immune-related adverse events, researchers are trying to uncouple the antitumour activity associated with immune checkpoint inhibitor therapy from the immune-related adverse events, to preserve antitumour activity without adverse events.
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Affiliation(s)
- Annu Susan George
- Department of Medical Oncology, Lakeshore Hospital, Cochin, Kerala, India
| | - Cornelius J Fernandez
- Department of Endocrinology, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - Dilip Eapen
- Department of Endocrinology, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - Joseph M Pappachan
- Department of Endocrinology & Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Manchester Metropolitan University, Manchester, UK
- The University of Manchester, Manchester, UK
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7
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Zhai Y, Ye X, Hu F, Xu J, Guo X, Zhou X, Zheng Y, Zhao X, Xu X, Cao Y, He J. Metabolic and Nutritional Disorders Following the Administration of Immune Checkpoint Inhibitors: A Pharmacovigilance Study. Front Endocrinol (Lausanne) 2021; 12:809063. [PMID: 35145482 PMCID: PMC8821653 DOI: 10.3389/fendo.2021.809063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/28/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Although several metabolic and nutritional disorders (MNDs) have been reported in the recipients of immune checkpoint inhibitors (ICIs), these events have not been fully captured and comprehensively characterized in real-world population. OBJECTIVES To provide complete metabolic and nutritional toxicity profiles after ICIs (single and combined) initiation through an integrated big database. METHODS Reporting odds ratios (ROR) and information component (IC) based on statistical shrinkage transformation were utilized to perform disproportionality analysis using the US Food and Drug Administration Adverse Events Reporting System. Both ROR and IC were used to calculate disproportionality when compared with the whole database, but only ROR was used when comparison was made for different ICI strategies. Only when both the lower limits of 95% confidence intervals (CIs) for ROR (ROR025) and IC (IC025) exceeded specified threshold values (1 and 0, respectively) was regarded as a signal. RESULTS A total of 29,294,335 records were involved and 8,662 records were for MNDs in patients exposed to ICIs. Statistically significant association was detected between ICIs use and total MNDs (IC025/ROR025 = 1.06/2.19). For monotherapy, three ICI monotherapies (anti-PD-1, anti-PDL-1, and anti-CTLA-4) were all disproportionately associated with MNDs. Statistically significant differences in reporting frequencies also emerged when comparing anti-PD-1 with anti-PD-L1/anti-CTLA-4 monotherapy, with RORs of 1.11 (95%CI 1.01-1.21), and 1.35 (95%CI 1.23-1.48), respectively. Notably, combination therapy was associated with a higher reporting frequency of theses toxicities compared to monotherapy with a ROR of 1.56 (95%CI 1.48-1.64). Additionally, disproportionality analysis at High-level Group Term level highlighted eight broad entities of MNDs. Further disproportionality analysis at Preferred Term level indicated a wide range and varied strength of signals. For ICI monotherapy, nivolumab and pembrolizumab showed the broadest spectrum of MNDs. For combination therapy, a variety of signals were detected for nivolumab + ipilimumab therapy even comparable to two PD-1 monotherapies. CONCLUSION Metabolic and nutritional complications could be provoked by ICI monotherapy (especially anti-PD-1) and further reinforced by combination therapy. Clinicians and patients should be informed about these potential risks that might be encountered in real-world practice. Aforehand education and regular monitoring of related biochemical parameters (calcium, sodium, potassium, protein) are recommended to ensure better cancer survivorship.
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Affiliation(s)
- Yinghong Zhai
- Tongji University School of Medicine, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Fangyuan Hu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
- Department of Medical Service, Naval Hospital of Eastern Theater Zhoushan, Zhejiang, China
| | - Jinfang Xu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Xiaojing Guo
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Xiang Zhou
- Tongji University School of Medicine, Shanghai, China
| | - Yi Zheng
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Xinxin Zhao
- Tongji University School of Medicine, Shanghai, China
| | - Xiao Xu
- Tongji University School of Medicine, Shanghai, China
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jia He
- Tongji University School of Medicine, Shanghai, China
- Department of Health Statistics, Second Military Medical University, Shanghai, China
- *Correspondence: Jia He,
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8
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George AS, Fernandez CJ, Eapen D, Pappachan JM. Organ-specific Adverse Events of Immune Checkpoint Inhibitor Therapy, with Special Reference to Endocrinopathies. EUROPEAN ENDOCRINOLOGY 2021. [DOI: 10.17925/ee.2021.1.1.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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9
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Workeneh BT, Jhaveri KD, Rondon-Berrios H. Hyponatremia in the cancer patient. Kidney Int 2020; 98:870-882. [DOI: 10.1016/j.kint.2020.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/28/2020] [Accepted: 05/11/2020] [Indexed: 02/08/2023]
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10
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Stelmachowska-Banaś M, Czajka-Oraniec I. Management of endocrine immune-related adverse events of immune checkpoint inhibitors: an updated review. Endocr Connect 2020; 9:R207-R228. [PMID: 33064663 PMCID: PMC7576644 DOI: 10.1530/ec-20-0342] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/16/2020] [Indexed: 12/18/2022]
Abstract
Immune checkpoint inhibitors (ICIs) belong to a new group of anticancer drugs targeting T-cell proteins involved in the activation of immune response toward malignancies. Their introduction into clinical practice was a milestone in modern cancer treatment. However, the significant advantage of ICIs over conventional chemotherapy in terms of therapeutic efficacy is accompanied by new challenges related to specific side effects. ICI-induced immune system activation could lead to the loss of self-tolerance, presenting as autoimmune inflammation and dysfunction of various tissues and organs. Thus, the typical side effects of ICIs include immune-related adverse events (irAEs), among which endocrine irAEs, affecting numerous endocrine glands, have been commonly recognized. This review aimed to outline the current knowledge regarding ICI-induced endocrine disorders from a clinical perspective. We present updated information on the incidence and clinical development of ICI-induced endocrinopathies, including the most frequent thyroiditis and hypophysitis, the rarely observed insulin-dependent diabetes mellitus and primary adrenal insufficiency, and the recently described cases of hypoparathyroidism and lipodystrophy. Practical guidelines for monitoring, diagnosis, and treatment of ICI-related endocrine toxicities are also offered. Rising awareness of endocrine irAEs among oncologists, endocrinologists, and other health professionals caring for patients receiving ICIs could contribute to better safety and efficacy. As immunotherapy becomes widespread and approved for new types of malignancies, increased incidences of endocrine irAEs are expected in the future.
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Affiliation(s)
- Maria Stelmachowska-Banaś
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Polska, Poland
- Correspondence should be addressed to M Stelmachowska-Banaś:
| | - Izabella Czajka-Oraniec
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Polska, Poland
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11
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Verzicco I, Regolisti G, Quaini F, Bocchi P, Brusasco I, Ferrari M, Passeri G, Cannone V, Coghi P, Fiaccadori E, Vignali A, Volpi R, Cabassi A. Electrolyte Disorders Induced by Antineoplastic Drugs. Front Oncol 2020; 10:779. [PMID: 32509580 PMCID: PMC7248368 DOI: 10.3389/fonc.2020.00779] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/22/2020] [Indexed: 12/23/2022] Open
Abstract
The use of antineoplastic drugs has a central role in treatment of patients affected by cancer but is often associated with numerous electrolyte derangements which, in many cases, could represent life-threatening conditions. In fact, while several anti-cancer agents can interfere with kidney function leading to acute kidney injury, proteinuria, and hypertension, in many cases alterations of electrolyte tubular handling and water balance occur. This review summarizes the mechanisms underlying the disturbances of sodium, potassium, magnesium, calcium, and phosphate metabolism during anti-cancer treatment. Platinum compounds are associated with sodium, potassium, and magnesium derangements while alkylating agents and Vinca alkaloids with hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH). Novel anti-neoplastic agents, such as targeted therapies (monoclonal antibodies, tyrosine kinase inhibitors, immunomodulators, mammalian target of rapamycin), can induce SIADH-related hyponatremia and, less frequently, urinary sodium loss. The blockade of epidermal growth factor receptor (EGFR) by anti-EGFR antibodies can result in clinically significant magnesium and potassium losses. Finally, the tumor lysis syndrome is associated with hyperphosphatemia, hypocalcemia and hyperkalemia, all of which represent serious complications of chemotherapy. Thus, clinicians should be aware of these side effects of antineoplastic drugs, in order to set out preventive measures and start appropriate treatments.
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Affiliation(s)
- Ignazio Verzicco
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Giuseppe Regolisti
- Unità di Ricerca sulla Insufficienza Renale Acuta e Cronica, Unità di Nefrologia, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Federico Quaini
- Ematologia e Oncologia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Pietro Bocchi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Irene Brusasco
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Massimiliano Ferrari
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Giovanni Passeri
- Unità di Endocrinologia e Malattie Osteometaboliche, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Valentina Cannone
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Pietro Coghi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Enrico Fiaccadori
- Unità di Ricerca sulla Insufficienza Renale Acuta e Cronica, Unità di Nefrologia, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Alessandro Vignali
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Riccardo Volpi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
- Unità di Endocrinologia e Malattie Osteometaboliche, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Aderville Cabassi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
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12
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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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13
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Sbardella E, Minnetti M, Pofi R, Cozzolino A, Greco E, Gianfrilli D, Isidori AM. Late Effects of Parasellar Lesion Treatment: Hypogonadism and Infertility. Neuroendocrinology 2020; 110:868-881. [PMID: 32335548 DOI: 10.1159/000508107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/21/2020] [Indexed: 11/19/2022]
Abstract
Central hypogonadism, also defined as hypogonadotropic hypogonadism, is a recognized complication of hypothalamic-pituitary-gonadal axis damage following treatment of sellar and parasellar masses. In addition to radiotherapy and surgery, CTLA4-blocking antibodies and alkylating agents such as temozolomide can also lead to hypogonadism, through different mechanisms. Central hypogonadism in boys and girls may lead to pubertal delay or arrest, impairing full development of the genitalia and secondary sexual characteristics. Alternatively, cranial irradiation or ectopic hormone production may instead cause early puberty, affecting hypothalamic control of the gonadostat. Given the reproductive risks, discussion of fertility preservation options and referral to reproductive specialists before treatment is essential. Steroid hormone replacement can interfere with other replacement therapies and may require specific dose adjustments. Adequate gonadotropin stimulation therapy may enable patients to restore gametogenesis and conceive spontaneously. When assisted reproductive technology is needed, protocols must be tailored to account for possible long-term gonadotropin insufficiency prior to stimulation. The aim of this review was to provide an overview of the risk factors for hypogonadism and infertility in patients treated for parasellar lesions and to give a summary of the current recommendations for management and follow-up of these dysfunctions in such patients. We have also briefly summarized evidence on the physiological role of pituitary hormones during pregnancy, focusing on the management of pituitary deficiencies.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Ermanno Greco
- Center for Reproductive Medicine, European Hospital, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy,
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Izzedine H. [Renal toxicities of targeted therapies in oncology]. Nephrol Ther 2019; 16:1-8. [PMID: 31818703 DOI: 10.1016/j.nephro.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/23/2019] [Indexed: 02/01/2023]
Abstract
The advent of new molecules oncology including targeted therapies, has resulted in improved patient survival over standard chemotherapy. The renal toxicities of these anticancer agents are more and more recognized and vary according to the targeted therapeutic target. This article reviews the renal toxicity associated with targeted anticancer therapies directed against Epidermal growth factor receptor, Human epidermal growth factor-2, B-rapidly accelerated fibrosarcoma, Mitogen-activated protein kinase, Anaplastic lymphoma kinase, Programmed cell death-1/programmed cell death ligand-1, Cytotoxic T lymphocyte antigen-4 and Vascular endothelial growth factor/receptor. The early diagnosis and management of these renal adverse events is essential for the clinician who cares for such patients.
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Affiliation(s)
- Hassan Izzedine
- Ramsay GDS, service de néphrologie, hôpital privé des Peupliers, 8, place de l'Abbé-Henocque, 75013 Paris, France.
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15
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Simeone E, Grimaldi AM, Festino L, Trojaniello C, Vitale MG, Vanella V, Palla M, Ascierto PA. Immunotherapy in metastatic melanoma: a novel scenario of new toxicities and their management. Melanoma Manag 2019; 6:MMT30. [PMID: 31871619 PMCID: PMC6920742 DOI: 10.2217/mmt-2019-0005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Checkpoint inhibitors can cause an imbalance in immune tolerance that may clinically manifest as immune-related adverse events (irAEs). These events may involve many organs and tissues, including the skin, gastrointestinal (GI) tract, liver, endocrine system, kidneys, central nervous system (CNS), eyes and lungs. The incidence of irAEs appears to be lower with anti-programmed death antigen-1/programmed death antigen-ligand-1 agents than with the anti-cytotoxic T-lymphocyte-associated protein-4 antibody ipilimumab. Combined immunotherapy does not appear to be associated with novel safety signals compared with monotherapy, but more organs may be involved. Increased experience and the use of algorithms for the most common irAEs have resulted in severe toxicity and related deaths being reduced. However, continuous vigilance, especially regarding less common events, is needed to better characterize the wide spectrum of clinical manifestations.
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Affiliation(s)
- Ester Simeone
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Antonio M Grimaldi
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Lucia Festino
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Claudia Trojaniello
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Maria G Vitale
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Vito Vanella
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Marco Palla
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Paolo A Ascierto
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
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Abstract
Immunomodulatory antibodies that directly trigger and reawaken suppressed T-cell effector function are termed 'checkpoint inhibitors'. CTLA-4 and PD-1/PD-L1 molecules are the most studied inhibitory immune check points against cancer and because of this therapeutic property have entered the clinic for treating a variety of tumor types. The results so far demonstrate a positive impact on cancer remission. Preclinical studies have demonstrated that targeting a number of other T-cell surface molecules including both positive and negative immune regulators, also possesses strong antitumor activity. Some of these molecules have already entered clinical trials. In this report, we briefly highlight the status of these immune checkpoint inhibitors and discuss their side effects and future directions for their use.
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Affiliation(s)
- Dass S Vinay
- Section of Clinical Immunology, Allergy & Rheumatology, School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Byoung S Kwon
- Section of Clinical Immunology, Allergy & Rheumatology, School of Medicine, Tulane University, New Orleans, LA 70112, USA.,Eutilex Institute for Biomedical Research, Suite #1401 Daeryung Technotown 17, Gasan digital 1-ro 25, Geumcheon-gu, Seoul Korea
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17
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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: 105] [Impact Index Per Article: 21.0] [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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18
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Jannin A, Merlen E, Do Cao C, Penel N. [Autoimmune hypophysitis associated with new anti-cancer immunotherapies]. Bull Cancer 2018; 105:275-280. [PMID: 29475597 DOI: 10.1016/j.bulcan.2017.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 10/11/2017] [Accepted: 10/28/2017] [Indexed: 12/31/2022]
Abstract
Recently developed immunotherapeutic agents, like anti-cytotoxic T lymphocyte antigen 4 antibody (CTLA4), anti-programmed cell death 1 (PD1) or anti-programmed cell death-ligand 1 (PDL1), have demonstrated substantial potential for the treatment of a variety of malignancies. Autoimmune side effects from these agents are diverse and can include multiple endocrinopathies like immunotherapy induced hypophysitis (IH). These toxicities appear to be more frequent in patients receiving anti-CTLA4 antibody compared to PD1/PDL1 agents. The diagnosis of IH is generally based on the presence of new hypopituitarism without an alternative etiology and radiographic pituitary enlargement or not while on treatment with Immunotherapy. Patients with IH frequently present non-specifics symptoms like headache, fatigue or weakness. ACTH and TSH deficiencies are more frequent. TSH and gonadotrophin deficiencies may be reversible but ACTH deficiency appears permanent. Glucocorticoid and thyroid hormone replacement should be instituted early after the diagnosis of IH, androgen replacement can be deferred initially and discussed by the patient. High-dose glucocorticoid does not improve the outcome of IH and should be reserved for patients with persistent severe headache, severe hyponatremia or visual defects. Patient education, early identification by measuring TSH, free thyroxine, morning ACTH and cortisol levels before each treatment cycle and proper treatment are the core of IH management.
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Affiliation(s)
- Arnaud Jannin
- CHRU de Lille, hôpital C.-Huriez, service d'endocrinologie-métabolisme, 59000 Lille, France
| | - Emilie Merlen
- CHRU de Lille, hôpital C.-Huriez, service d'endocrinologie-métabolisme, 59000 Lille, France
| | - Christine Do Cao
- CHRU de Lille, hôpital C.-Huriez, service d'endocrinologie-métabolisme, 59000 Lille, France
| | - Nicolas Penel
- Centre Oscar-Lambret, département de cancérologie générale, 3, rue F.-Combemale, 59020 Lille, France; CHRU de Lille, hôpital Claude-Huriez, service d'oncologie médicale, 59000 Lille, France.
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19
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Iglesias P. Cancer immunotherapy-induced endocrinopathies: Clinical behavior and therapeutic approach. Eur J Intern Med 2018; 47:6-13. [PMID: 28826822 DOI: 10.1016/j.ejim.2017.08.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/11/2017] [Accepted: 08/16/2017] [Indexed: 12/29/2022]
Abstract
Cancer immunotherapy has proven to be effective in a wide variety of tumors. The use of immune checkpoint blocking monoclonal antibodies has become a standard treatment regimen in some of them as advanced melanoma. However, given the mechanism of action, its use may be associated with immune-related adverse events that may complicate the clinical course and prognosis of patients. Among these are autoimmune endocrine adverse effects, such as hypophysitis, hypo and hyperthyroidism, and adrenal insufficiency. This review focuses on the most relevant and new aspects related to the incidence, clinical presentation, diagnosis and treatment of these adverse effects associated with different types of immune checkpoint inhibitors in cancer immunotherapy.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. de Colmenar, Km 9.100, 28034 Madrid, Spain.
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20
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Nichetti F, Lobefaro R, Pagani F, Randon G, Corti F, de Braud F, Celio L, Platania M. "Systemic strategy at the patient's service": a congress report on supportive care in oncology. TUMORI JOURNAL 2017; 103:0. [PMID: 28777425 DOI: 10.5301/tj.2017.17342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2017] [Indexed: 11/20/2022]
Affiliation(s)
- Federico Nichetti
- Medical Oncology, Fondazione IRCCS - Istituto Nazionale dei Tumori, Milan - Italy
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21
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Abstract
PURPOSE OF REVIEW Three mAbs targeting immune checkpoint proteins are available for the treatment of patients with melanoma, lung, and kidney cancer, and their use will likely expand in the future to additional tumor types. We here update the literature on the incidence and pathophysiology of endocrine toxicities induced by these agents, and discuss management guidance. RECENT FINDINGS Immune checkpoint inhibition may trigger autoimmune syndromes involving different organs, including several endocrine glands (pituitary, thyroid, adrenals, and endocrine pancreas). Hypophysitis is more frequently associated with ipilimumab, whereas the incidence of thyroid dysfunction is higher with nivolumab/pembrolizumab. Primary adrenal insufficiency can rarely occur with either treatment. Autoimmune diabetes is very rare. As hypophysitis and adrenalitis may be life-threatening, endocrinological evaluation is essential particularly in patients developing fatigue and other symptoms consistent with adrenal insufficiency. Corticosteroids should be promptly used when hypophysitis-induced adrenal insufficiency or adrenalitis are diagnosed, but not in thyroiditis or diabetes. No impact of corticosteroids on the efficacy/activity of immune checkpoint-inhibiting drugs is reported. Hormonal deficiencies are often permanent. SUMMARY In absence of predicting factors, accurate information to patients provided by the oncology care team is essential for early diagnosis and to limit the consequences of checkpoint inhibition-related endocrine toxicity.
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Abstract
The use of immune checkpoint inhibitors (ICI) in several cancers is expanding; however, their use in patients with cancer and an organ transplant is very limited. In this review, we summarize the literature and the experience of anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and anti-programmed cell death protein 1 (PD-1) inhibitors in the organ transplant patient. The immunology of CTLA-4 and PD-1 inhibitors and their role in tolerance breakdown is also reviewed. While CTLA-4 inhibitors have been successfully used in kidney, liver, and heart transplant patients without rejection, the uses of PD-1 inhibitors and the combination therapy of CTLA-4 and PD-1 inhibitors have been associated with cellular- and antibody-mediated rejection. While immunosuppression minimization is needed for ICI to provide the best response when managing transplant patients who develop malignancy, this can lead to rejection episodes. Prevention strategies, such as the use of ongoing steroids and sirolimus, could prevent rejection while sustaining tumor response. As the experience grows with these agents, we will learn more about tolerance and the use of ICI in the organ transplant patient. Therefore, the use of an immune checkpoint blockade in transplantation is extremely difficult, and future research should focus on finding the right balance between unleashing the immune system to provide an anti-tumor effect but at the same time sustaining tolerance so that rejection is suppressed. Also, the ability to identify biomarkers that may predict rejection early and allow for the fine tuning of doses and frequencies of drug administration would be very helpful.
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Wanchoo R, Karam S, Uppal NN, Barta VS, Deray G, Devoe C, Launay-Vacher V, Jhaveri KD. Adverse Renal Effects of Immune Checkpoint Inhibitors: A Narrative Review. Am J Nephrol 2017; 45:160-169. [PMID: 28076863 DOI: 10.1159/000455014] [Citation(s) in RCA: 232] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cancer immunotherapy, such as anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and anti-programmed death 1 (PD-1), has revolutionized the treatment of malignancies by engaging the patient's own immune system against the tumor rather than targeting the cancer directly. These therapies have demonstrated a significant benefit in the treatment of melanomas and other cancers. SUMMARY In order to provide an extensive overview of the renal toxicities induced by these agents, a Medline search was conducted of published literature related to ipilimumab-, pembrolizumab-, and nivolumab-induced kidney toxicity. In addition, primary data from the initial clinical trials of these agents and the FDA adverse reporting system database were also reviewed to determine renal adverse events. Acute interstitial nephritis (AIN), podocytopathy, and hyponatremia were toxicities caused by ipilimumab. The main adverse effect associated with both the PD-1 inhibitors was AIN. The onset of kidney injury seen with PD-1 inhibitors is usually late (3-10 months) compared to CTLA-4 antagonists related renal injury, which happens earlier (2-3 months). PD-1 as opposed to CTLA-4 inhibitors has been associated with kidney rejection in transplantation. Steroids appear to be effective in treating the immune-related adverse effects noted with these agents. Key Message: Although initially thought to be rare, the incidence rates of renal toxicities might be higher (9.9-29%) as identified by recent studies. As a result, obtaining knowledge about renal toxicities of immune checkpoint inhibitors is extremely important.
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Affiliation(s)
- Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Great Neck, USA
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Jhaveri KD, Wanchoo R, Sakhiya V, Ross DW, Fishbane S. Adverse Renal Effects of Novel Molecular Oncologic Targeted Therapies: A Narrative Review. Kidney Int Rep 2016; 2:108-123. [PMID: 29318210 PMCID: PMC5720524 DOI: 10.1016/j.ekir.2016.09.055] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 12/21/2022] Open
Abstract
Novel targeted anti-cancer therapies have resulted in improvement in patient survival compared to standard chemotherapy. Renal toxicities of targeted agents are increasingly being recognized. The incidence, severity, and pattern of renal toxicities may vary according to the respective target of the drug. Here we review the adverse renal effects associated with a selection of currently approved targeted cancer therapies, directed to EGFR, HER2, BRAF, MEK, ALK, PD1/PDL1, CTLA-4, and novel agents targeted to VEGF/R and TKIs. In summary, electrolyte disorders, renal impairment and hypertension are the most commonly reported events. Of the novel targeted agents, ipilumumab and cetuximab have the most nephrotoxic events reported. The early diagnosis and prompt recognition of these renal adverse events are essential for the general nephrologist taking care of these patients.
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Affiliation(s)
- Kenar D Jhaveri
- Department of Internal Medicine, Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
| | - Rimda Wanchoo
- Department of Internal Medicine, Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
| | - Vipulbhai Sakhiya
- Department of Internal Medicine, Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
| | - Daniel W Ross
- Department of Internal Medicine, Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
| | - Steven Fishbane
- Department of Internal Medicine, Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
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Liamis G, Filippatos TD, Elisaf MS. Electrolyte disorders associated with the use of anticancer drugs. Eur J Pharmacol 2016; 777:78-87. [PMID: 26939882 DOI: 10.1016/j.ejphar.2016.02.064] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/23/2016] [Accepted: 02/26/2016] [Indexed: 12/23/2022]
Abstract
The use of anticancer drugs is beneficial for patients with malignancies but is frequently associated with the occurrence of electrolyte disorders, which can be hazardous and in many cases fatal. The review presents the electrolyte abnormalities that can occur with the use of anticancer drugs and provides the related mechanisms. Platinum-containing anticancer drugs induce hypomagnesemia, hypokalemia and hypocalcemia. Moreover, platinum-containing drugs are associated with hyponatremia, especially when combined with large volumes of hypotonic fluids aiming to prevent nephrotoxicity. Alkylating agents have been linked with the occurrence of hyponatremia [due to syndrome of inappropriate antidiuretic hormone secretion (SIADH)] and Fanconi's syndrome (hypophosphatemia, aminoaciduria, hypouricemia and/or glucosuria). Vinca alkaloids are associated with hyponatremia due to SIADH. Epidermal growth factor receptor monoclonal antibody inhibitors induce hypomagnesemia, hypokalemia and hypocalcemia. Other, monoclonal antibodies, such as cixutumumab, cause hyponatremia due to SIADH. Tyrosine kinase inhibitors are linked to hyponatremia and hypophosphatemia. Mammalian target of rapamycin inhibitors induce hyponatremia (due to aldosterone resistance), hypokalemia and hypophosphatemia. Other drugs such as immunomodulators or methotrexate have been also associated with hyponatremia. The administration of estrogens at high doses, streptozocin, azacitidine and suramin may induce hypophosphatemia. Finally, the drug-related tumor lysis syndrome is associated with hyperphosphatemia, hyperkalemia and hypocalcemia. The prevention of electrolyte derangements may lead to reduction of adverse events during the administration of anticancer drugs.
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Affiliation(s)
- George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Theodosios D Filippatos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses S Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece.
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Rossi E, Sgambato A, De Chiara G, Casaluce F, Losanno T, Sacco PC, Santabarbara G, Gridelli C. Endocrinopathies induced by immune-checkpoint inhibitors in advanced non-small cell lung cancer. Expert Rev Clin Pharmacol 2016; 9:419-28. [PMID: 26681547 DOI: 10.1586/17512433.2016.1133289] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The advent of immunotherapy has recently expanded the therapeutic options in advanced non-small cell lung cancer (NSCLC). In these patients, the recent efficacy demonstration of antibodies against immune checkpoints: the anti-programmed death-1 (PD-1) and anti-programmed death ligand-1 (PD-L1), has led to approval of nivolumab and pembrolizumab (anti-PD-1) in the treatment of advanced NSCLC. The mechanism of action of checkpoint inhibitors explains the development of autoimmune diseases as a side-effect of these medications. Among these, a spectrum of endocrine disorders has been also reported. This manuscript focuses particularly on endocrine disorders induced by immuno-checkpoint inhibitors employed in NSCLC, in order to suggest the strategies for their diagnosis and effective management.
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Affiliation(s)
- Emanuela Rossi
- a Division of Medical Oncology , "S. G. Moscati" Hospital , Avellino , Italy
| | - Assunta Sgambato
- b Department of Clinical and Experimental Medicine , Second University of Naples , Naples , Italy
| | - Giovanni De Chiara
- c Division of Pathologic Anatomy , "S. G. Moscati" Hospital , Avellino , Italy
| | - Francesca Casaluce
- b Department of Clinical and Experimental Medicine , Second University of Naples , Naples , Italy
| | - Tania Losanno
- d Department of Experimental Medicine , "Sapienza" University , Rome , Italy
| | - Paola Claudia Sacco
- a Division of Medical Oncology , "S. G. Moscati" Hospital , Avellino , Italy
| | | | - Cesare Gridelli
- a Division of Medical Oncology , "S. G. Moscati" Hospital , Avellino , Italy
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27
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Bertrand A, Kostine M, Barnetche T, Truchetet ME, Schaeverbeke T. Immune related adverse events associated with anti-CTLA-4 antibodies: systematic review and meta-analysis. BMC Med 2015; 13:211. [PMID: 26337719 PMCID: PMC4559965 DOI: 10.1186/s12916-015-0455-8] [Citation(s) in RCA: 494] [Impact Index Per Article: 54.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/18/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Targeting CTLA-4 is a recent strategic approach in cancer control: blocking CTLA-4 enhances an antitumor immunity by promoting T-cell activation and cytotoxic T-lymphocyte proliferation. This induction of a tolerance break against the tumor may be responsible for immune-related adverse events (irAEs). Our objective was to assess the incidence and nature of irAEs in oncologic patients receiving anti-CTLA-4 antibodies (ipilimumab and tremelimumab). METHODS A systematic search of literature up to February 2014 was performed in MEDLINE, EMBASE, and Cochrane databases to identify relevant articles. Paired reviewers independently selected articles for inclusion and extracted data. Pooled incidence was calculated using R(©), package meta. RESULTS Overall, 81 articles were included in the study, with a total of 1265 patients from 22 clinical trials included in the meta-analysis. Described irAEs consisted of skin lesions (rash, pruritus, and vitiligo), colitis, and less frequently hepatitis, hypophysitis, thyroiditis, and some rare events such as sarcoidosis, uveitis, Guillain-Barré syndrome, immune-mediated cytopenia and polymyalgia rheumatic/Horton. The overall incidence of all-grade irAEs was 72 % (95 % CI, 65-79 %). The overall incidence of high-grade irAEs was 24 % (95 % CI, 18-30 %). The risk of developing irAEs was dependent of dosage, with incidence of all-grade irAEs being evaluated to 61 % (95 % CI, 56-66 %) for ipilimumab 3 mg/kg and 79 % (95 % CI, 69-89 %) for ipilimumab 10 mg/kg. Death due to irAEs occurred in 0.86 % of patients. The median time of onset of irAEs was about 10 weeks (IQR, 6-12) after the onset of treatment, corresponding with the first three cycles but varied according to the organ system involved. Such immune activation could also be indicative for tumor-specific T-cell activation and irAE occurrence was associated with clinical response to CTLA-4 blocking in 60 % of patients. CONCLUSION The price of potential long-term survival to metastatic tumors is an atypical immune toxicity, reflecting the mechanism of action of anti-CTLA-4 antibodies. A better knowledge of these irAEs and its management in a multidisciplinary approach will help to reduce morbidity and therapy interruptions.
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Affiliation(s)
- Anne Bertrand
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
| | - Marie Kostine
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
| | - Thomas Barnetche
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
| | - Marie-Elise Truchetet
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
- Laboratoire d'Immunologie, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France.
| | - Thierry Schaeverbeke
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
- Unité sous Contrat, Infections à Mycoplasmes et à Chlamydia chez l'Homme, Université de Bordeaux, Bordeaux, France.
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Endocrinopatías autoinmunitarias inducidas por anticuerpos inmunomoduladores en el tratamiento del cáncer. Med Clin (Barc) 2015; 145:264-8. [DOI: 10.1016/j.medcli.2015.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/03/2015] [Accepted: 02/07/2015] [Indexed: 01/22/2023]
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Mahzari M, Liu D, Arnaout A, Lochnan H. Immune checkpoint inhibitor therapy associated hypophysitis. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2015; 8:21-8. [PMID: 25861234 PMCID: PMC4376202 DOI: 10.4137/cmed.s22469] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/26/2015] [Accepted: 01/28/2015] [Indexed: 12/30/2022]
Abstract
Ipilimumab is a monoclonal antibody directed against CTLA4 T-lymphocyte antigen used as cancer therapy. Immune-related adverse events are common side effects and may include hypophysitis-related hypopituitarism. The clinical features of six patients with ipilimumab-induced hypophysitis (IH) are described. The clinical features of IH reported in clinical trials, including the incidence of IH by gender and the likelihood of adrenal axis recovery, are summarized. Following the development of IH, most patients remain on glucocorticoid replacement despite efforts to withdraw therapy. Analysis of gender information in published clinical trials suggests that men are more prone to developing IH than women, and few patients fully recover the pituitary–adrenal axis function. Ipilimumab and other drugs within its class are likely to be used to treat many forms of cancer. Endocrinologists should anticipate a significant increase in the incidence of autoimmune hypophysitis. Strategies for early detection of IH and long-term management should be considered.
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Affiliation(s)
- Moeber Mahzari
- Division of Endocrinology and Metabolism, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Canada
| | - Dora Liu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Canada
| | - Amel Arnaout
- Division of Endocrinology and Metabolism, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Canada
| | - Heather Lochnan
- Division of Endocrinology and Metabolism, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Canada
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Anticytotoxic T-lymphocyte antigen-4 induced autoimmune hypophysitis: a case report and literature review. Case Rep Endocrinol 2015; 2015:570293. [PMID: 25694832 PMCID: PMC4324809 DOI: 10.1155/2015/570293] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/09/2015] [Indexed: 11/17/2022] Open
Abstract
Objective. We describe a case of autoimmune hypophysitis induced by the anticytotoxic T-lymphocyte antigen-4 (CTLA-4) agent, ipilimumab. Methods. Case presentation and review of the literature. Results. Autoimmune hypophysitis, a previously described rare disorder, is being recognized more frequently as a side effect of novel immunomodulatory agents used in the treatment of malignancies such as melanoma. CTLA-4 agents are associated with immune-related adverse effects (irAE) which occur as a result of activation (or lack of inactivation) of the immune response. This impacts not only malignant cells but also different host organ-systems. Autoimmune hypophysitis is one of several endocrinopathies associated with these agents. Conclusion. It is important that endocrinologists become familiar with the endocrinopathies, such as autoimmune hypophysitis, associated with new immunomodulator agents which are being used with increasing frequency to treat a variety of malignancies.
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Marlier J, Cocquyt V, Brochez L, Van Belle S, Kruse V. Ipilimumab, not just another anti-cancer therapy: hypophysitis as side effect illustrated by four case-reports. Endocrine 2014; 47:878-83. [PMID: 24554495 DOI: 10.1007/s12020-014-0199-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/31/2014] [Indexed: 12/14/2022]
Abstract
Ipilimumab is a monoclonal antibody that blocks cytotoxic T-lymphocyte antigen4 (CTLA-4), an inhibitory molecule typically expressed on T cells. Blockade of CTLA-4 induces an overall activation of T cells, including an immune-mediated anti-tumour response. Unfortunately, this broad T cell stimulation also causes immune-related adverse events (irAEs), such as dermatitis, colitis, hepatitis and hypophysitis. Ipilimumab is currently available in Belgium as a second line of treatment for patients with advanced melanoma, and is used at a dose of 3 mg/kg of body weight, although higher doses were previously used (up to 10 mg/kg). We performed a retrospective analysis to identify melanoma patients treated with ipilimumab at the Ghent University Hospital between 2010 and 2013. Data on symptoms, stage and timing of ipilimumab, response and adverse events were collected with a special attention to endocrine disturbances, going from a limited involvement of one endocrine axis to development of a hypophysitis. We identified a total of 39 patients with stage III (No. = 7) or stage IV (No. = 32) melanoma, who received a dose of 3 (No. = 31) or 10 (No. = 8) mg/kg. Six patients developed a severe form of irAEs, including one case of colitis (2 %), one case of sarcoidosis (2 %) and 4 cases (10 %) of hypophysitis. Hypophysitis developed between the second and fourth cycle of ipilimumab administration and was independent of the dose used. We describe four cases of involvement of the pituitary gland during treatment with ipilimumab. When managed with vigilant monitoring and high-dose corticosteroids, the acute symptoms resolve, but lifelong hormone substitution therapy can be necessary. Involvement of the pituitary axes is a severe side effect of treatment with ipilimumab with an urgent need for the correct medical intervention.
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Affiliation(s)
- Joke Marlier
- Department of Medical Oncology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium,
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32
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Iwama S, De Remigis A, Callahan MK, Slovin SF, Wolchok JD, Caturegli P. Pituitary expression of CTLA-4 mediates hypophysitis secondary to administration of CTLA-4 blocking antibody. Sci Transl Med 2014; 6:230ra45. [PMID: 24695685 DOI: 10.1126/scitranslmed.3008002] [Citation(s) in RCA: 456] [Impact Index Per Article: 45.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hypophysitis is a chronic inflammation of the pituitary gland of unknown (primary forms) or recognizable (secondary forms) etiology, such as the use of ipilimumab in cancer immunotherapy. Ipilimumab, which blocks the T cell inhibitory molecule CTLA-4 (cytotoxic T lymphocyte antigen-4), induces hypophysitis in about 4% of patients through unknown mechanisms. We first established a model of secondary hypophysitis by repeated injections of a CTLA-4 blocking antibody into SJL/J or C57BL/6J mice, and showed that they developed lymphocytic infiltration of the pituitary gland and circulating pituitary antibodies. We next assessed the prevalence of pituitary antibodies in a cohort of 20 patients with advanced melanoma or prostate cancer, 7 with a clinical diagnosis of hypophysitis, before and after ipilimumab administration. Pituitary antibodies, negative at baseline, developed in the 7 patients with hypophysitis but not in the 13 without it; these antibodies predominantly recognized thyrotropin-, follicle-stimulating hormone-, and corticotropin-secreting cells. We then hypothesized that the injected CTLA-4 antibody could cause pituitary toxicity if bound to CTLA-4 antigen expressed "ectopically" on pituitary endocrine cells. Pituitary glands indeed expressed CTLA-4 at both RNA and protein levels, particularly in a subset of prolactin- and thyrotropin-secreting cells. Notably, these cells became the site of complement activation, featuring deposition of C3d and C4d components and an inflammatory cascade akin to that seen in type II hypersensitivity. In summary, the study offers a mechanism to explain the pituitary toxicity observed in patients receiving ipilimumab, and highlights the utility of measuring pituitary antibodies in this form of secondary hypophysitis.
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Affiliation(s)
- Shintaro Iwama
- Department of Pathology, Johns Hopkins University, Baltimore, MD 21205, USA
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33
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Zatelli MC, Ambrosio MR, Bondanelli M, Degli Uberti E. Pituitary side effects of old and new drugs. J Endocrinol Invest 2014; 37:917-23. [PMID: 25070042 DOI: 10.1007/s40618-014-0133-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/08/2014] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Pituitary function is influenced by several drugs, including anti-depressant, opioids, glucocorticoids, chemotherapeutic agents, immunomodulators and the newly developed tyrosine kinase inhibitors. In most instances, treatment with these drugs negatively affects pituitary function, but in rare cases an activation of specific hypothalamic-pituitary axes may be observed. Several of the observed pituitary side effects are reversible after drug withdrawal, but pituitary function deficiency may persist long-term. In addition to the well known drugs, recent evidence shows that also non-steroidal anti-inflammatory drugs impair gonadal axis at pituitary level, while antipsychotic phenothiazines alter TSH response to TRH and TSH levels. Atypical antipsychotics may decrease TRH-stimulated TSH. Tricyclic antidepressant drugs interfere with the hypothalamo-pituitary-thyroid axis by decreasing TSH response to TRH. Anabolic-androgenic steroids, marijuana, cocaine, methamphetamines, and opioid narcotics negatively impact fertility, also acting at hypothalamic-pituitary level. CONCLUSIONS Many of the drugs administered routinely in the intensive care unit significantly impact the hypothalamic-pituitary axis. Therefore, an increased awareness on pituitary side effects of drugs commonly used in clinical practice is necessary in order to rule out possible pharmacological interference when assessing patients with pituitary deficiencies.
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Affiliation(s)
- Maria Chiara Zatelli
- Department of Medical Sciences, Section of Endocrinology, University of Ferrara, Via Savonarola 9, 44100, Ferrara, Italy,
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Ipilimumab treatment associated pituitary hypophysitis: clinical presentation and imaging diagnosis. Clin Neurol Neurosurg 2014; 125:125-30. [PMID: 25127260 DOI: 10.1016/j.clineuro.2014.06.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 06/05/2014] [Accepted: 06/08/2014] [Indexed: 01/18/2023]
Abstract
Ipilimumab is an immunomodulating drug for use in treatment of unresectable or metastatic melanoma with autoimmune lymphocytic hypophysitis as a reported complication. We describe three recent cases of ipilimumab associated autoimmune hypophysitis (IAH) at our institution, and provide a selected literature review showing its variable clinical presentation, imaging appearance and treatment in order to expedite early and appropriate IAH management. Patients had variable clinical presentation of hypophysitis, including headache, fatigue, visual changes, endocrinopathy, and/or hyponatremia. Contrast enhanced MRI showed symmetric pituitary gland and stalk enlargement in all of our cases and received a presumptive diagnosis of IAH. Following cessation of therapy and treatment there was normalization of pituitary morphology at follow-up MRI and return to clinical baseline. Varying clinical presentation can complicate the diagnosis of lymphocytic hypophysitis. One must be cognizant of its overall clinical and radiologic picture in patients receiving ipilimumab, now commonly used for the treatment of metastatic melanoma.
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Torino F, Barnabei A, Paragliola RM, Marchetti P, Salvatori R, Corsello SM. Endocrine side-effects of anti-cancer drugs: mAbs and pituitary dysfunction: clinical evidence and pathogenic hypotheses. Eur J Endocrinol 2013; 169:R153-64. [PMID: 24001893 DOI: 10.1530/eje-13-0434] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
mAbs are established targeted therapies for several diseases, including hematological and solid malignancies. These agents have shown a favorable toxicity profile, but, despite their high selectivity, new typical side-effects have emerged. In cancer patients, pituitary dysfunction may be mainly due to brain metastases or primary tumors and to related surgery and radiotherapy. Anticancer agents may induce hypopituitarism in patients cured for childhood cancers. These agents infrequently affect pituitary function in adult cancer patients. Notably, hypophysitis, a previously very rare disease, has emerged as a distinctive side-effect of ipilimumab and tremelimumab, two mAbs inhibiting the cytotoxic T-lymphocyte antigen-4 receptor, being occasionally seen with nivolumab, another immune checkpoint inhibitor. Enhanced antitumor immunity is the suggested mechanism of action of these drugs and autoimmunity the presumptive mechanism of their toxicity. Recently, ipilimumab has been licensed for the treatment of patients affected by metastatic melanoma. With the expanding use of these drugs, hypophysitis will be progressively encountered by oncologists and endocrinologists in clinical practice. The optimal management of this potentially life-threatening adverse event needs a rapid and timely diagnostic and therapeutic intervention. Hypopituitarism caused by these agents is rarely reversible, requiring prolonged or lifelong substitutive hormonal treatment. Further studies are needed to clarify several clinical and pathogenic aspects of this new form of secondary pituitary dysfunction.
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Affiliation(s)
- Francesco Torino
- Department of Systems Medicine, Chair of Medical Oncology, Tor Vergata University of Rome, Rome, Italy
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36
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Fecher LA, Agarwala SS, Hodi FS, Weber JS. Ipilimumab and its toxicities: a multidisciplinary approach. Oncologist 2013; 18:733-43. [PMID: 23774827 DOI: 10.1634/theoncologist.2012-0483] [Citation(s) in RCA: 213] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The treatment for metastatic melanoma has evolved significantly in the past few years. Ipilimumab, an immunotherapy, is now in mainstream oncology practice given that it has shown improved overall survival in randomized clinical trials. Other immune modulating agents, such as programmed death receptor-1 and programmed death receptor ligand-1 antibodies, are showing promise in early clinical trials. This manuscript will review ipilimumab and its most common side effects. Immune-related adverse events (irAEs) are important to recognize early, and their presentation, timing of onset, and general recommendations for workup and management will be reviewed. Assembling a multidisciplinary team, as well as thorough education of the patient, is recommended to optimize patient care.
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Affiliation(s)
- Leslie A Fecher
- University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania, USA.
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37
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de Hollanda A, Aranda GB, Mora M, Gaba L, Halperin I. [Ipilimumab, a cause of autoimmune hypophysitis]. ACTA ACUST UNITED AC 2013; 60:604-6. [PMID: 23607982 DOI: 10.1016/j.endonu.2013.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/20/2013] [Accepted: 01/22/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Ana de Hollanda
- Servicio de Endocrinología y Nutrición, Hospital Clínic, Universitat de Barcelona, Barcelona, España.
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38
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Autoimmune hypophysitis in a patient successfully treated with anti-ctla-4 (Ipilimumab) immunotherapy for metastatic malignant melanoma. Pathology 2013. [DOI: 10.1097/01.pat.0000426945.15005.b4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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39
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First reports of serious adverse drug reactions in recent weeks. DRUGS & THERAPY PERSPECTIVES 2012. [DOI: 10.1007/bf03262136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Allix I, Rohmer V. [Hypophysitis: increasingly complex clinicopathological spectrum!]. ANNALES D'ENDOCRINOLOGIE 2012; 73 Suppl 1:S17-25. [PMID: 23089377 DOI: 10.1016/s0003-4266(12)70011-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hypophysitis is a chronic inflammation of the pituitary gland that comprises an increasingly complex clinicopathological spectrum. Lymphocytic and granulomatous hypophysitis are the most common forms, but new variants have recently been reported such as IgG4-related hypophysitis that is identified by well-defined criteria. For the first time, hypophysitis in ANCA-associated vasculitides has been reported. Monoclonal antibodies directed against the cytotoxic T-lymphocyte antigen-4 (CTLA-4), investigated in metastatic melanoma, can induce hypophysitis. Hypophysitis's pathogenesis remains obscure but several candidate pituitary autoantigens have been described in the last decade, although none has proven useful as a diagnostic tool.
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Affiliation(s)
- I Allix
- Département d'Endocrinologie Diabétologie Nutrition, CHU Angers, 4 rue Larrey 49933 Angers cedex 9, France.
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41
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Abstract
PURPOSE OF REVIEW To discuss the multiple forms of hypophysitis, the various methods of classification, the recent findings in pituitary autoimmunity and novel methods of treating resistant or recurrent hypophysitis. (January 2010-December 2011). RECENT FINDINGS Multiple novel presentations of hypophysitis have been described including cytotoxic T-lymphocyte antigen-4 antibody-related hypophysitis, an adverse event associated with a novel treatment for cancer, Food and Drug Administration approved for use in the treatment of metastatic melanoma. A rare, but newly described entity of immunoglobulin G4 related plasmacytic hypophysitis has been described and reviewed. Multiple investigations addressing the role of autoimmunity in the diagnosis and pathogenesis of hypophysitis have been reported with positive antipituitary antibodies found in patients with autoimmune hypophysitis, other autoimmune diseases, and nonimmune-related pituitary diseases. Several case series and case reports present new associations with concomitant diseases and novel therapy for cases requiring treatment when standard therapy fails or is contraindicated. SUMMARY Hypophysitis is a rare disease with multiple subtypes. The description of hypophysitis related to cytotoxic T-lymphocyte antigen-4 antibody treatment is one of the first descriptions of hypophysitis triggered by medication. As the use of this novel treatment for cancer increases, so must our awareness of immune-related adverse effects and their treatment. Pituitary autoimmunity is a challenging field with multiple discoveries reported to help further our understanding of the disease and assist in diagnosis. Insufficient sensitivity and specificity of the currently reported methods prevents recommending measurement of antipituitary antibodies as standard of care in the diagnosis of hypophysitis. The treatment of hypophysitis remains controversial with recommendations ranging from hormonal replacement to newly described therapies such as azathioprine and radiation.
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Affiliation(s)
- John D Carmichael
- The Pituitary Center, Department of Medicine, Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2012; 19:328-37. [PMID: 22760515 DOI: 10.1097/med.0b013e3283567080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Juszczak A, Gupta A, Karavitaki N, Middleton MR, Grossman AB. Ipilimumab: a novel immunomodulating therapy causing autoimmune hypophysitis: a case report and review. Eur J Endocrinol 2012; 167:1-5. [PMID: 22495490 DOI: 10.1530/eje-12-0167] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Ipilimumab (Yervoy; Medarex and Bristol-Myers Squibb) is a human MAB against cytotoxic T-lymphocyte antigen 4, which enhances co-stimulation of cytotoxic T-lymphocytes, resulting in their proliferation and an anti-tumour response. It is licensed for the treatment of unresectable or metastatic malignant melanoma, while multiple clinical trials using this medication in the treatment of other malignancies are ongoing. As a clinical response to ipilimumab results from immunostimulation, predictably it generates autoimmunity as well, causing immune-related adverse events in the majority of patients. Of those, endocrinopathies are frequently seen, and in particular, autoimmune lymphocytic hypophysitis with anterior panhypopituitarism has been reported a number of times in North America. We present a case of a male referred to our department with manifestations of anterior panhypopituitarism after his third dose of ipilimumab for metastatic malignant melanoma, and we discuss the management of his case in the light of previous reports. We also review the published literature on the presenting symptoms, time to presentation, investigations, imaging, treatment and follow-up of ipilimumab-induced autoimmune lymphocytic hypophysitis.
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Affiliation(s)
- Agata Juszczak
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford OX3 7LE, UK
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44
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Verschraegen C. The monoclonal antibody to cytotoxic T lymphocyte antigen 4, ipilimumab, in the treatment of melanoma. Cancer Manag Res 2012; 4:1-8. [PMID: 22346364 PMCID: PMC3278204 DOI: 10.2147/cmar.s15551] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Cytotoxic T lymphocyte antigen 4 (CTLA-4) is an inhibitory regulator of the T-cell immune response against tumor cells. Ipilimumab is a monoclonal antibody directed against CTLA-4. OBJECTIVE This review describes the basic mechanism of ipilimumab and discusses data available to date with regards to its safety and efficacy profile. METHODS Data from clinical trials including abstracts was reviewed using the PubMed Database, as well as the American Society of Clinical Oncology Abstract Database. CONCLUSION CTLA-4 inhibition with a monoclonal antibody is usually well tolerated and has efficacy as a therapeutic agent in a variety of cancers. The classical response interpretation has changed because of the delayed mechanism of action. The toxicities are autoimmune events and guidelines for treatment of these effects are discussed. Therapy with ipilimumab leads to durable responses. The first two Phase III randomized studies showed an improvement of survival at 1, 2, and 3 years. Other studies are currently underway to better understand the optimal treatment administration of ipilimumab in melanoma.
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Affiliation(s)
- Claire Verschraegen
- Professor of Medicine, Division of Hematology Oncology, University of Vermont, Vermont Cancer Center, VT, USA
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45
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Wang XY, Zuo D, Sarkar D, Fisher PB. Blockade of cytotoxic T-lymphocyte antigen-4 as a new therapeutic approach for advanced melanoma. Expert Opin Pharmacother 2011; 12:2695-706. [PMID: 22077831 PMCID: PMC3711751 DOI: 10.1517/14656566.2011.629187] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The incidence of melanoma continues to rise, and prognosis in patients with metastatic melanoma remains poor. The cytotoxic T-lymphocyte antigen-4 (CTLA-4) serves as one of the primary immune check points and downregulates T-cell activation pathways. Enhancing T-cell activation by antibody blockade of CTLA-4 provides a new approach to overcome tumor-induced immune tolerance. Recently, anti-CTLA-4 therapy demonstrated significant clinical benefits in patients with metastatic melanoma, which led to the approval of ipilimumab by the FDA in early 2011. AREAS COVERED The fundamental concepts underlying CTLA-4 blockade-potentiated immune activation are presented in this paper, along with the scientific rationale for and the preclinical evidence supporting CTLA-4-targeted cancer immunotherapy. It also provides an update on clinical trials with anti-CTLA-4 inhibitors and discusses the associated autoimmune toxicity. EXPERT OPINION Given that overall survival is the only validated end point for anti-CTLA-4 therapy, the clinical implications of the antigen or tumor-specific immunity in patients remain to be clarified. Additional research is necessary to elucidate the prognostic significance of immune-related side effects and significantly optimize the treatment regimens. An improved understanding of the mechanisms of action of CTLA-4 antibodies may also culminate in wide-ranging clinical applications of this new therapy for other tumor types.
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Affiliation(s)
- Xiang-Yang Wang
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Institute of Molecular Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
| | - Daming Zuo
- Department of Immunology, Southern Medical University, Guangzhou, 510515, China
| | - Devanand Sarkar
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Institute of Molecular Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
| | - Paul B. Fisher
- Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Institute of Molecular Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
- VCU Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, VA23298, USA
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