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Ruggiero R, Di Napoli R, Balzano N, Ruggiero D, Riccardi C, Anatriello A, Cantone A, Sportiello L, Rossi F, Capuano A. Immune-related adverse events and immune checkpoint inhibitors: a focus on neurotoxicity and clinical management. Expert Rev Clin Pharmacol 2023; 16:423-434. [PMID: 37144360 DOI: 10.1080/17512433.2023.2211262] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) represent an innovative therapeutic approach of oncologic diseases. In Europe, this therapeutic class currently includes eight agents: ipilimumab, pembrolizumab, nivolumab, atezolizumab, avelumab, cemiplimab, durvalumab and dostarlimab. Despite their proved clinical benefits, they can induce immune related adverse events (irADRs), that can also involve the nervous system. AREAS COVERED Despite their rarity, neurological irADRs related to ICI-treatments can lead to serious and dangerous complications, highlighting the importance of a strict monitoring of patients. This review aims to summarize the safety profile of ICIs, focusing on their possible neurotoxicity and their management. EXPERT OPINION Considering the clinical relevance of ICIs-induced irADRs and that the underlying mechanisms are still not completely understood, the use of ICIs requires extensive safety monitoring. Before to prescribe immunotherapy, oncologists should identify possible individual risk factors that may favor the onset of irADRs. Oncologists and general practitioners should inform and educate patients about the specific toxicities of immunological checkpoint inhibitors, including nervous ones. They should be carefully monitored at least 6 months after the end of treatment. ICIs-related nervous toxicities require a multidisciplinary management, in which neurologists and clinical pharmacologists should participate.
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Affiliation(s)
- Rosanna Ruggiero
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Raffaella Di Napoli
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Nunzia Balzano
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Donatella Ruggiero
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Consiglia Riccardi
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Antonietta Anatriello
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Andrea Cantone
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Liberata Sportiello
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Francesco Rossi
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
| | - Annalisa Capuano
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
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Müller-Jensen L, Zierold S, Versluis JM, Boehmerle W, Huehnchen P, Endres M, Mohr R, Compter A, Blank CU, Hagenacker T, Meier F, Reinhardt L, Gesierich A, Salzmann M, Hassel JC, Ugurel S, Zimmer L, Banks P, Spain L, Soon JA, Enokida T, Tahara M, Kähler KC, Seggewiss-Bernhardt R, Harvey C, Long GV, Schöberl F, von Baumgarten L, Hundsberger T, Schlaak M, French LE, Knauss S, Heinzerling LM. Characteristics of immune checkpoint inhibitor-induced encephalitis and comparison with HSV-1 and anti-LGI1 encephalitis: A retrospective multicentre cohort study. Eur J Cancer 2022; 175:224-235. [PMID: 36155116 DOI: 10.1016/j.ejca.2022.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/06/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Abstract
AIM Immune checkpoint inhibitor-induced encephalitis (ICI-iE) is a rare but life-threatening toxicity of immune checkpoint inhibitor treatment. We aim to identify the characteristics of ICI-iE and describe factors that discriminate it from herpes simplex virus (HSV)-1 encephalitis and anti-leucine-rich glioma-inactivated 1 (anti-LGI1) encephalitis, as two alternative entities of encephalitis. METHODS In this retrospective multicentre cohort study, we collected patients with ICI-iE reported to the Side Effect Registry Immuno-Oncology from January 2015 to September 2021 and compared their clinical features and outcome with 46 consecutive patients with HSV-1 or anti-LGI1 encephalitis who were treated at a German neurological referral centre. RESULTS Thirty cases of ICI-iE, 25 cases of HSV-1 encephalitis and 21 cases of anti-LGI1 encephalitis were included. Clinical presentation of ICI-iE was highly variable and resembled that of HSV-1 encephalitis, while impairment of consciousness (66% vs. 5%, p = .007), confusion (83% vs. 43%; p = .02), disorientation (83% vs. 29%; p = .007) and aphasia (43% vs. 0%; p = .007) were more common in ICI-iE than in anti-LGI1 encephalitis. Antineuronal antibodies (17/18, 94%) and MRI (18/30, 60%) were mostly negative in ICI-iE, but cerebrospinal fluid (CSF) showed pleocytosis and/or elevated protein levels in almost all patients (28/29, 97%). Three patients (10%) died of ICI-iE. Early immunosuppressive treatment was associated with better outcome (r = 0.43). CONCLUSIONS ICI-iE is a heterogeneous entity without specific clinical features. CSF analysis has the highest diagnostic value, as it reveals inflammatory changes in most patients and enables the exclusion of infection. Early treatment of ICI-iE is essential to prevent sequelae and death.
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Affiliation(s)
- Leonie Müller-Jensen
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany.
| | - Sarah Zierold
- SERIO Side Effect Registry Immuno-Oncology, Germany; Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany
| | - Judith M Versluis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Wolfgang Boehmerle
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany
| | - Petra Huehnchen
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Endres
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117 Berlin, Germany; Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Cluster of Excellence, 10117 Berlin, Germany; Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Stroke Research Berlin, 10117 Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Raphael Mohr
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Hepatology & Gastroenterology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Annette Compter
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Christian U Blank
- Department of Medical Oncology, Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Center Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Center Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Anja Gesierich
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Martin Salzmann
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Selma Ugurel
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Patricia Banks
- Andrew Love Cancer Centre, University Hospital Geelong, Geelong, Australia
| | - Lavinia Spain
- Medical Oncology Department, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Jennifer A Soon
- Medical Oncology Department, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Tomohiro Enokida
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan
| | - Makoto Tahara
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan
| | - Katharina C Kähler
- Department of Dermatology, Venerology and Allergology, University of Schleswig-Holstein Hospital, Campus Kiel, Germany
| | | | - Catriona Harvey
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Georgina V Long
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Florian Schöberl
- Department of Neurology, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany
| | - Louisa von Baumgarten
- Department of Neurology, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany; Division of Neuro-Oncology, Department of Neurosurgery, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany
| | - Thomas Hundsberger
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Max Schlaak
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Dermatology, Venerology and Allergology, Charitéplatz 1, 10117 Berlin, Germany
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany; Dr. Philip Frost, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Samuel Knauss
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; SERIO Side Effect Registry Immuno-Oncology, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Lucie M Heinzerling
- SERIO Side Effect Registry Immuno-Oncology, Germany; Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany; Department of Dermatology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
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