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Goldman A, Galper BEL, Druyan A, Grossman C, Sharif K, Shechtman L, Moshkovits Y, Lahat A, Ben-Zvi I. Adverse cardiovascular events in rheumatoid arthritis patients treated with JAK inhibitors: An analysis of postmarketing spontaneous safety reports. Semin Arthritis Rheum 2024; 67:152461. [PMID: 38772185 DOI: 10.1016/j.semarthrit.2024.152461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/14/2024] [Accepted: 04/29/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVES The ORAL Surveillance trial, a postmarketing safety clinical trial, found an increased risk of adverse cardiovascular events and venous thromboembolism (VTE) in patients treated with Janus Kinase (JAK) inhibitors compared to tumor necrosis factor (TNF) inhibitors. However, additional studies yielded mixed results and data on other JAK inhibitors are limited. METHODS A retrospective, pharmacovigilance study using the FDA adverse event reporting system (FAERS) to assess reporting of adverse cardiovascular events following treatment with JAK inhibitors in rheumatoid arthritis (RA) patients between January 2015 and June 2023. To identify disproportionately increased reporting, an adjusted reporting odds ratio (adj.ROR) was calculated with a multivariable logistic regression model. RESULTS We identified safety reports of 75,407 RA patients treated with JAK inhibitors (tofacitinib, n = 52,181; upadacitinib, n = 21,006; baricitinib, n = 2,220) and 303,278 patients treated with biologic disease-modifying antirheumatic drugs (bDMARDs; TNF inhibitors, rituximab, and tocilizumab). The mean age was 61.2(±12) and 59.0(±13), respectively; 82 % and 81 % were women. Compared to bDMARDs, JAK inhibitors were associated with an increased reporting of VTE [n = 1,393, adj.ROR=2.11 (1.97-2.25)], stroke [n = 973, adj.ROR=1.25 (1.16-1.34)], ischemic heart disease [IHD, n = 999, adj.ROR=1.23 (1.13-1.33)], peripheral edema [n = 2699, adj.ROR=1.22 (1.17-1.28)], and tachyarrhythmias [n = 370, adj.ROR=1.15 (1.00-1.33)]. Most of the events occurred in the first year after treatment initiation. When different JAK inhibitors were compared, VTE, stroke, and IHD were more frequently reported with upadacitinib and baricitinib than tofacitinib. When stratified by age category, all safety signals were statistically significant in patients aged≤65 years. CONCLUSION In this global postmarketing study, JAK inhibitors are associated with increased reporting of VTE, stroke, IHD, and tachyarrhythmias. These adverse events were reported following all JAK inhibitors that were studied, suggesting a class effect.
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Affiliation(s)
- Adam Goldman
- Department of Internal Medicine F, Sheba Medical Center, Ramat-Gan, Israel; Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; The Sheba Talpiot Medical Leadership Program, Sheba Medical Center, Ramat-Gan, Israel
| | | | - Amit Druyan
- Department of Internal Medicine F, Sheba Medical Center, Ramat-Gan, Israel; School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel‑Aviv, Israel
| | - Chagai Grossman
- Department of Internal Medicine F, Sheba Medical Center, Ramat-Gan, Israel; School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel‑Aviv, Israel
| | - Kassem Sharif
- School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel‑Aviv, Israel; Department of Gastroenterology, Sheba Medical Center, Ramat-Gan, Israel
| | - Liran Shechtman
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Yonatan Moshkovits
- Department of Internal Medicine F, Sheba Medical Center, Ramat-Gan, Israel; School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel‑Aviv, Israel
| | - Adi Lahat
- School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel‑Aviv, Israel; Department of Gastroenterology, Sheba Medical Center, Ramat-Gan, Israel
| | - Ilan Ben-Zvi
- Department of Internal Medicine F, Sheba Medical Center, Ramat-Gan, Israel; The Sheba Talpiot Medical Leadership Program, Sheba Medical Center, Ramat-Gan, Israel; School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel‑Aviv, Israel.
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Pasoto SG, Franco AS, Silva CA, Bonfa E. Sicca syndrome/Sjögren's disease associated with cancer immunotherapy: a narrative review on clinical presentation, biomarkers, and management. Expert Rev Clin Immunol 2024:1-19. [PMID: 38903050 DOI: 10.1080/1744666x.2024.2370327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 06/17/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION Almost one-quarter of immune checkpoint inhibitor (ICI) recipients experience sicca syndrome, while Sjögren's disease (SjD) is estimated at 0.3-2.5%, possibly underreported. AREAS COVERED This narrative review (Medline/Embase until January/31/2024) addresses the pathophysiology, incidence, demographic/clinical features, biomarkers, labial salivary gland biopsy (LSGB), fulfillment of the idiopathic SjD (iSjD) classificatory criteria, differential diagnosis, and management of sicca syndrome/SjD associated with ICIs. EXPERT OPINION SjD associated with ICIs is underdiagnosed, since studies that performed the mandatory SjD investigation identified that 40-60% of patients with sicca syndrome associated with ICIs meet the iSjD classificatory criteria. LSGB played a fundamental role in recognizing these cases, as most of them had negative anti-Ro/SS-A antibody. Despite the finding of focal lymphocytic sialoadenitis in LSGB samples mimicking iSjD, immunohistochemical analysis provided novel evidence of a distinct pattern for sicca syndrome/SjD associated with ICIs compared to iSjD. The former has scarcity of B lymphocytes, which are a hallmark of iSjD. Additionally, patients with sicca syndrome/SjD associated with ICIs have demographical/clinical/serological and treatment response dissimilarities compared to iSjD. Dryness symptoms are more acute in the former than in iSjD, with predominance of xerostomia over xerophthalmia, and partial/complete response to glucocorticoids. Dryness symptoms in ICI-treated patients warrant prompt SjD investigation.
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Affiliation(s)
- Sandra Gofinet Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - André Silva Franco
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Clovis Artur Silva
- Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Eloisa Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
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Won T, Song EJ, Kalinoski HM, Moslehi JJ, Čiháková D. Autoimmune Myocarditis, Old Dogs and New Tricks. Circ Res 2024; 134:1767-1790. [PMID: 38843292 DOI: 10.1161/circresaha.124.323816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/08/2024] [Indexed: 06/12/2024]
Abstract
Autoimmunity significantly contributes to the pathogenesis of myocarditis, underscored by its increased frequency in autoimmune diseases such as systemic lupus erythematosus and polymyositis. Even in cases of myocarditis caused by viral infections, dysregulated immune responses contribute to pathogenesis. However, whether triggered by existing autoimmune conditions or viral infections, the precise antigens and immunologic pathways driving myocarditis remain incompletely understood. The emergence of myocarditis associated with immune checkpoint inhibitor therapy, commonly used for treating cancer, has afforded an opportunity to understand autoimmune mechanisms in myocarditis, with autoreactive T cells specific for cardiac myosin playing a pivotal role. Despite their self-antigen recognition, cardiac myosin-specific T cells can be present in healthy individuals due to bypassing the thymic selection stage. In recent studies, novel modalities in suppressing the activity of pathogenic T cells including cardiac myosin-specific T cells have proven effective in treating autoimmune myocarditis. This review offers an overview of the current understanding of heart antigens, autoantibodies, and immune cells as the autoimmune mechanisms underlying various forms of myocarditis, along with the latest updates on clinical management and prospects for future research.
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Affiliation(s)
- Taejoon Won
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois Urbana-Champaign (T.W.)
| | - Evelyn J Song
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco (E.J.S., J.J.M.)
| | - Hannah M Kalinoski
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD (H.M.K., D.Č)
| | - Javid J Moslehi
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco (E.J.S., J.J.M.)
| | - Daniela Čiháková
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD (H.M.K., D.Č)
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD (D.Č)
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Batton R, Matte P, Aoun M, Lefèvre A, Joubert PE. [Immune-checkpoint inhibitors : from love at first sight to heartbreak]. Med Sci (Paris) 2024; 40:581-583. [PMID: 38986109 DOI: 10.1051/medsci/2024076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024] Open
Affiliation(s)
- Romain Batton
- M2 Immunologie translationnelle et biothérapies, Parcours Immunologie, Master Biologie Moléculaire et cellulaire, Sorbonne Université, Paris, France
| | - Paul Matte
- M2 Immunologie translationnelle et biothérapies, Parcours Immunologie, Master Biologie Moléculaire et cellulaire, Sorbonne Université, Paris, France
| | - Michael Aoun
- M2 Immunologie translationnelle et biothérapies, Parcours Immunologie, Master Biologie Moléculaire et cellulaire, Sorbonne Université, Paris, France
| | - Auréline Lefèvre
- M2 Immunologie intégrative et systématique, Parcours Immunologie, Master Biologie Moléculaire et cellulaire, Sorbonne Université, Paris, France
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Palaskas NL, Ali HJ, Koutroumpakis E, Ganatra S, Deswal A. Cardiovascular toxicity of immune therapies for cancer. BMJ 2024; 385:e075859. [PMID: 38749554 DOI: 10.1136/bmj-2023-075859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
In addition to conventional chemoradiation and targeted cancer therapy, the use of immune based therapies, specifically immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T cell therapy (CAR-T), has increased exponentially across a wide spectrum of cancers. This has been paralleled by recognition of off-target immune related adverse events that can affect almost any organ system including the cardiovascular system. The use of ICIs has been associated with myocarditis, a less common but highly fatal adverse effect, pericarditis and pericardial effusions, vasculitis, thromboembolism, and potentially accelerated atherosclerosis. CAR-T resulting in a systemic cytokine release syndrome has been associated with myriad cardiovascular consequences including arrhythmias, myocardial infarction, and heart failure. This review summarizes the current state of knowledge regarding adverse cardiovascular effects associated with ICIs and CAR-T.
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Affiliation(s)
| | - Hyeon-Ju Ali
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sarju Ganatra
- Lahey Hospital and Medical Center, Burlington, MA 01805
| | - Anita Deswal
- University of Texas MD Anderson Cancer Center, Houston, TX, USA 01805
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Jayan A, Mammen AL, Suarez-Almazor ME. Immune Checkpoint Inhibitor-induced Myositis. Rheum Dis Clin North Am 2024; 50:281-290. [PMID: 38670726 DOI: 10.1016/j.rdc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Myositis induced by immune checkpoint inhibitors (ICIs) is an infrequent, potentially fatal, immune-related adverse event. It has higher incidence in patients who receive combination ICI therapy compared to monotherapy. Patients can present with clinical manifestation symptoms of myositis alone or in combination with myocarditis and/or myasthenia gravis, which significantly worsens the course and prognosis. Diagnosis can generally be made on the basis of clinical presentation, elevation of muscle enzymes, and electromyographic changes, but some patients may require a muscle biopsy. The first line of therapy is high-dose corticosteroids, followed by immunosuppression, plasmapheresis, or intravenous immunoglobulin in patients with severe disease.
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Affiliation(s)
- Athira Jayan
- Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Andrew L Mammen
- Department of Neurology, Johns Hopkins University School of Medicine; Department of Medicine, Johns Hopkins University School of Medicine; Muscle Disease Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 50, Room 1146, Bethesda, MD 20892, USA
| | - Maria E Suarez-Almazor
- Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Yang H, Ding Z, An Z, Zhao Y, Lu H. Immune checkpoint inhibitor related myositis: an observational, retrospective, pharmacovigilance study. Expert Opin Drug Saf 2024:1-6. [PMID: 38629402 DOI: 10.1080/14740338.2024.2343023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/26/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) show promise in cancer treatment, but recent cases highlight myositis as a serious complication. RESEARCH DESIGN AND METHODS We did a retrospective study on drug safety using FAERS data up to Q3 2022, focusing on immune checkpoint inhibitors (ICIs) and myositis. We used IC and ROR to assess the association. Logistic regression in R 3.2.5 helped identify factors linked to fatal outcomes. RESULTS We identified 558 cases of ICIs-associated myositis. Our study found a significant link between ICIs and myositis (ROR 15.54 [14.23-16.96], IC 3.79 [3.66-3.92], see Figure 1). Notably, myositis was more common in patients on ICI combination therapy compared to monotherapy (ROR 1.72 [1.39-2.11], IC 0.63 [0.30-0.93]). Age increased the risk of ICI-associated myositis and was also a factor in fatality (p = 0.011). Common accompanying adverse events included myocarditis (21.33%), severe myasthenia gravis (16.49%), and malignant neoplasm progression (8.06%). Fatal cases were more common when myositis was accompanied by myocarditis, severe myasthenia gravis, or malignant neoplasm progression. CONCLUSIONS Clinicians must note the risk of ICI-associated myositis, especially dangerous in older patients or when combined with other issues like myocarditis or severe myasthenia gravis.
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Affiliation(s)
- Hui Yang
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhexin Ding
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Zhuoling An
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yong Zhao
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
- Faculty of Synthetic Biology, Shenzhen University of Advanced Technology, Shenzhen, China
- CAS Key Laboratory of Quantitative Engineering Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hezhe Lu
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
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Gougis P, Jochum F, Abbar B, Dumas E, Bihan K, Lebrun-Vignes B, Moslehi J, Spano JP, Laas E, Hotton J, Reyal F, Hamy AS, Salem JE. Clinical spectrum and evolution of immune-checkpoint inhibitors toxicities over a decade-a worldwide perspective. EClinicalMedicine 2024; 70:102536. [PMID: 38560659 PMCID: PMC10981010 DOI: 10.1016/j.eclinm.2024.102536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/23/2024] [Accepted: 02/23/2024] [Indexed: 04/04/2024] Open
Abstract
Background Immune-checkpoint inhibitors (ICI) have revolutionized cancer treatment by harnessing the immune system but ICI can induce life-threatening immune-related adverse events (irAE) affecting every organ. Methods We extracted irAE from VigiBase, the international pharmacovigilance database, first reported in 2008 until 01/2023 to characterize irAE reporting trends, clinical features, risk factors and outcomes. Findings We distinguished 25 types of irAE (n = 50,347cases, single irAE/case in 84.9%). Cases mainly involved anti-PD1 (programmed-death-1) monotherapy (62.4%) in male (61.7%) aged 64.3 ± 12.6 years. After 2020 vs. prior to 2016, proportion of anti-CTLA4 (Cytotoxic-T-Lymphocyte-Antigen-4) monotherapy prescription almost vanished (1.6% vs. 47%, respectively) contrasting with increased use of anti-PDL1 (PD1-ligand) monotherapy (18% vs. 0.9%) and anti-CTLA4+anti-PD(L)1 combination (20% vs. 8.9%). Anti-LAG3 (Lymphocyte-Activation-Gene-3) prescription was limited (<1%) in the studied timeframe. After 2020, over 14 different cancer types were treated vs. almost exclusively melanoma and lung cancers before 2016. Overall, the most reported irAE were skin reactions (22.9%), pneumonitis (18.5%), enterocolitis (14.4%) and thyroiditis (12.1%). ICI-myotoxicities (6.6%) included myositis, myocarditis and myasthenia-gravis like syndrome and were the most overlapping irAE (up to 30% overlap, vs. <3% in general for other inter-irAE overlap). The top factors associated with specific irAE (odds-ratio>5) were presence of thymic cancer for ICI-myotoxicities or hepatitis; presence of melanoma for vitiligo, uveitis or sarcoidosis; specific types of ICI regimen (anti-LAG3 for meningitis, anti-CTLA4 for hypophysitis); and specific reporting regions (eastern Asia for cholangitis). Median time-to-onset ranged from 31 to 273 days, being shortest for myotoxicities and most delayed for skin-bullous auto-immune reactions. Overall fatality was highest for myocarditis = 27.6%, myasthenia = 23.1%, severe cutaneous adverse reactions (SCAR) = 22.1%, myositis = 21.9%, pneumonitis = 21%, and encephalomyelitis = 18%; generally decreasing after 2020, except for myasthenia and SCAR. When reported, irAE recurrence rate after rechallenge was 28.9% (n = 275/951). Interpretation This up-to-date comprehensive worldwide pharmacovigilance study defines the spectrum, characteristics, and evolution of irAE reporting summarizing over a decade of use. Multiple risk factors and clinical peculiarities for specific irAE have been identified as signals to guide clinical practice and future research. Funding Paul Gougis was supported by the academic program: "Contrats ED: Programme blanc Institut Curie PSL" for the conduct of his PhD. Baptiste Abbar was supported by "the Fondation ARC Pour le Rechercher Sur le Cancer". The RT2L research group (Institut Curie) was supported by the academic program "SHS INCa", Sanofi iTech award, and by Monoprix∗.
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Affiliation(s)
- Paul Gougis
- Residual Tumor & Response to Treatment Laboratory, RT2Lab, INSERM, U932 Immunity and Cancer, Institut Curie, Université Paris Cité, Paris 75005, France
- Department of Medical Oncology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris 75013, France
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Assistance Publique - Hôpitaux de Paris (AP-HP), Clinical Investigation Center (CIC-1901), Regional Pharmacovigilance Centre, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - Floriane Jochum
- Residual Tumor & Response to Treatment Laboratory, RT2Lab, INSERM, U932 Immunity and Cancer, Institut Curie, Université Paris Cité, Paris 75005, France
- Department of Gynecology, Strasbourg University Hospital, Strasbourg, France
| | - Baptiste Abbar
- Department of Medical Oncology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris 75013, France
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Assistance Publique - Hôpitaux de Paris (AP-HP), Clinical Investigation Center (CIC-1901), Regional Pharmacovigilance Centre, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
- Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm U1135, France
| | - Elise Dumas
- Residual Tumor & Response to Treatment Laboratory, RT2Lab, INSERM, U932 Immunity and Cancer, Institut Curie, Université Paris Cité, Paris 75005, France
| | - Kevin Bihan
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Assistance Publique - Hôpitaux de Paris (AP-HP), Clinical Investigation Center (CIC-1901), Regional Pharmacovigilance Centre, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - Bénédicte Lebrun-Vignes
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Assistance Publique - Hôpitaux de Paris (AP-HP), Clinical Investigation Center (CIC-1901), Regional Pharmacovigilance Centre, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
- EpiDermE, Epidemiology in Dermatology and Evaluation of Therapeutics, Paris Est Créteil University UPEC, Créteil F-94010, France
| | - Javid Moslehi
- Section of Cardio-oncology & Immunology, Cardiovascular Research Institute, University of California San Francisco School of Medicine, San Francisco, United States
| | - Jean-Philippe Spano
- Department of Medical Oncology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris 75013, France
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Assistance Publique - Hôpitaux de Paris (AP-HP), Clinical Investigation Center (CIC-1901), Regional Pharmacovigilance Centre, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
- INSERM, UMRS 1136, Paris, France
| | - Enora Laas
- Department of Breast, Gynecological and Reconstructive Surgery, Institut Curie, Université Paris Cité, Paris 75005, France
| | - Judicael Hotton
- Department of Surgical Oncology, Institut Godinot, Reims, France
| | - Fabien Reyal
- Residual Tumor & Response to Treatment Laboratory, RT2Lab, INSERM, U932 Immunity and Cancer, Institut Curie, Université Paris Cité, Paris 75005, France
- Department of Breast, Gynecological and Reconstructive Surgery, Institut Curie, Université Paris Cité, Paris 75005, France
- Department of Surgical Oncology, Institut Godinot, Reims, France
| | - Anne-Sophie Hamy
- Residual Tumor & Response to Treatment Laboratory, RT2Lab, INSERM, U932 Immunity and Cancer, Institut Curie, Université Paris Cité, Paris 75005, France
- Department of Medical Oncology, Institut Curie, Université Paris Cité, Paris 75005, France
| | - Joe-Elie Salem
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Assistance Publique - Hôpitaux de Paris (AP-HP), Clinical Investigation Center (CIC-1901), Regional Pharmacovigilance Centre, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
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Euvrard R, Robert M, Mainbourg S, Dalle S, Lega JC. Association between immune-related adverse events and prognosis in patients treated with immune checkpoint inhibitors in melanoma: A surrogacy analysis. Fundam Clin Pharmacol 2024; 38:369-379. [PMID: 38012082 DOI: 10.1111/fcp.12966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/10/2023] [Accepted: 10/26/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) represent a breakthrough in oncology in terms of prognosis and safety. They now constitute a cornerstone in the management of metastatic melanoma. However, a new kind of adverse event called immune-related adverse events (irAE) has emerged. These irAE could be conceptually considered as an indicator of the antitumoral immune response, but the association between irAE and prognosis is still a matter of debate. OBJECTIVE The purpose of this study was to investigate the association between the overall survival (OS) and the prevalence of irAE in melanoma. METHODS MEDLINE/PubMed, WebofScience, ClinicalTrials, and WHOTrials databases were searched to identify phase 3 randomized controlled trials (RCT) assessing ICI in melanoma and published up to April 2021. A weighted regression was performed to estimate this association according to standard method of surrogacy analysis. RESULTS A total of 14 RCT including 7646 patients (median age: 59.3 years) with melanoma were included. All types of ICI were represented (ipilimumab, tremelimumab, pembrolizumab, nivolumab, atezolizumab, as well as ipilimumab and nivolumab combination). irAE were frequent but rarely fatal. The combination of ICI caused more irAE than anti-PD1 (or PDL1) and anti-CTLA4 monotherapies. No relationship was found between the occurrence of irAE and OS (beta coefficient 0.078, R2 3%, p = 0.52), nor between cutaneous irAE and OS (beta coefficient 0.080, R2 6%, p = 0.33). CONCLUSION Although limited by the heterogeneity of ICI included in the regression and the low number of included RCT, the present study suggests an absence of association between irAE and prognosis in melanoma.
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Affiliation(s)
- Romain Euvrard
- Service de Médecine Interne et Pathologie Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, France
| | - Marie Robert
- Service de Médecine Interne et d'immunologie clinique, Université de Lyon 1, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Sabine Mainbourg
- Equipe Évaluation et Modélisations des Effets Thérapeutiques, UMR CRNS 5558, Université Claude Bernard Lyon 1, Lyon, France
- Lyon Immunopathology Federation (LIFe), Hospices Civils de Lyon, France
| | - Stéphane Dalle
- Service de Dermatologie, Hôpital Lyon Sud, Hospices Civils de Lyon, France
- ImmuCare (Immunology Cancer Research), Hospices Civils de Lyon, France
| | - Jean-Christophe Lega
- Equipe Évaluation et Modélisations des Effets Thérapeutiques, UMR CRNS 5558, Université Claude Bernard Lyon 1, Lyon, France
- Lyon Immunopathology Federation (LIFe), Hospices Civils de Lyon, France
- ImmuCare (Immunology Cancer Research), Hospices Civils de Lyon, France
- Service de Rhumatologie, Hôpital Lyon Sud, Hospices Civils de lyon, France
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Robert M, Lessard LER, Bouhour F, Petiot P, Fenouil T, Svahn J, Fiscus J, Fabien N, Perard L, Robinson P, Durieu I, Coury F, Streichenberger N, Hot A, Gallay L. Inaugural dropped head syndrome and camptocormia in inflammatory myopathies: a retrospective study. Rheumatology (Oxford) 2024; 63:506-515. [PMID: 37462538 PMCID: PMC10837000 DOI: 10.1093/rheumatology/kead347] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 06/27/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES Inaugural axial muscle involvement, defined as dropped head syndrome (DHS) and/or camptocormia (CC), is poorly described in inflammatory myopathies (IM). This study aimed to further characterize IM patients with inaugural DHS/CC, their outcome and care management. METHODS This retrospective study included IM patients diagnosed between 2000 and 2021. The main inclusion criterion was IM revealed by axial muscle deficit (DHS/CC). RESULTS Twenty-seven patients were included; median (IQR) age at first symptoms was 66.0 years (55.5-75.0); 21 were female (77.8%). There were nine IBM, 33.3%, nine overlap myositis (OM, 33.3%), five DM, 18.5%, two immune checkpoint inhibitor-related myositis (7.4%), one focal myositis (3.7%) and one myositis with anti-Hu antibodies (3.7%). Age at first symptoms was ≤70 years in 16 patients (59.3%), including all DM patients and 8/9 OM patients (88.9%). In this group, partial remission of the disease was obtained in 9/16 (56.3%) and complete remission in 1/16 patients (6.3%); regression of DHS/CC was achieved in 3/16 patients (18.8%). Conversely, in the group of 11 patients aged >70 years at first symptoms, there were eight IBM (72.7%). Partial remission was obtained in 5/11 patients (45.5%), the disease was stable in 6/11 patients (54.5%); no complete remission was obtained nor regression of DHS/CC. CONCLUSION The analysis of IM patients with inaugural DHS/CC delineates two groups of patients according to the age at first symptoms in terms of clinical and outcome specificities, and proposes an adapted diagnostic and care management approach to prevent long-term complications.
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Affiliation(s)
- Marie Robert
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Lola E R Lessard
- Service d'Electroneuromyographie et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- Laboratoire Physiopathologie et Génétique du Neurone et du Muscle (PGNM), CNRS UMR5261-INSERM U1315, Institut NeuroMyoGène-Université Claude Bernard Lyon 1, Lyon, France
| | - Françoise Bouhour
- Service d'Electroneuromyographie et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Philippe Petiot
- Service d'Electroneuromyographie et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Tanguy Fenouil
- Service de Cytologie et d'Anatomie Pathologique, Département de Neuropathologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
- Equipe Ribosome Traduction et Cancer, UMR Inserm 1052 CNRS 5286, Centre de Recherche en Cancérologie de Lyon, Lyon, France
| | - Juliette Svahn
- Service d'Electroneuromyographie et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Julie Fiscus
- Service d'Immunologie, UF Autoimmunité, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Nicole Fabien
- Service d'Immunologie, UF Autoimmunité, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Laurent Perard
- Service de Médecine Interne, Centre Hospitalier Saint Joseph Saint Luc, Lyon, France
| | - Philip Robinson
- Direction de la Recherche en Santé, Hospices Civils de Lyon, Lyon, France
| | - Isabelle Durieu
- Service de Médecine interne, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Fabienne Coury
- Département de Rhumatologie, Hôpital Lyon Sud, Hospices civils de Lyon, Pierre-Bénite, France
- Inserm UMR1033, Université Claude Bernard Lyon 1, Lyon, France
| | - Nathalie Streichenberger
- Laboratoire Physiopathologie et Génétique du Neurone et du Muscle (PGNM), CNRS UMR5261-INSERM U1315, Institut NeuroMyoGène-Université Claude Bernard Lyon 1, Lyon, France
- Service de Cytologie et d'Anatomie Pathologique, Département de Neuropathologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Arnaud Hot
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Laure Gallay
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Laboratoire Cell Therapy & Musculoskeletal Disorders, Université de Genève, Genève, Switzerland
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Nelke C, Schmid S, Kleefeld F, Schroeter CB, Goebel HH, Hoffmann S, Preuße C, Kölbel H, Meuth SG, Ruck T, Stenzel W. Complement and MHC patterns can provide the diagnostic framework for inflammatory neuromuscular diseases. Acta Neuropathol 2024; 147:15. [PMID: 38214778 PMCID: PMC10786976 DOI: 10.1007/s00401-023-02669-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 01/13/2024]
Abstract
Histopathological analysis stands as the gold standard for the identification and differentiation of inflammatory neuromuscular diseases. These disorders continue to constitute a diagnostic challenge due to their clinical heterogeneity, rarity and overlapping features. To establish standardized protocols for the diagnosis of inflammatory neuromuscular diseases, the development of cost-effective and widely applicable tools is crucial, especially in settings constrained by limited resources. The focus of this review is to emphasize the diagnostic value of major histocompatibility complex (MHC) and complement patterns in the immunohistochemical analysis of these diseases. We explore the immunological background of MHC and complement signatures that characterize inflammatory features, with a specific focus on idiopathic inflammatory myopathies. With this approach, we aim to provide a diagnostic algorithm that may improve and simplify the diagnostic workup based on a limited panel of stainings. Our approach acknowledges the current limitations in the field of inflammatory neuromuscular diseases, particularly the scarcity of large-scale, prospective studies that validate the diagnostic potential of these markers. Further efforts are needed to establish a consensus on the diagnostic protocol to effectively distinguish these diseases.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Simone Schmid
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Kleefeld
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
| | - Christina B Schroeter
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Hans-Hilmar Goebel
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Hoffmann
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
| | - Corinna Preuße
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
- Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Augustenburger Platz 1, 13353, Berlin, Germany
| | - Heike Kölbel
- Department of Neuropaediatrics, Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany.
- Leibniz Science Campus Chronic Inflammation, Berlin, Germany.
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12
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Zhao J, Dou Y, Liang G, Huang H, Hong K, Yang W, Zhou G, Sha B, Liu J, Zeng L. Global Publication Trends and Research Hotspots of the Immune System and Osteoporosis: A Bibliometric and Visualization Analysis from 2012 to 2022. Endocr Metab Immune Disord Drug Targets 2024; 24:455-467. [PMID: 37881072 DOI: 10.2174/0118715303257269231011073100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/10/2023] [Accepted: 09/15/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Osteoporosis (OP) is a systemic bone metabolism disorder in which the immune system and bone metabolism interact. OBJECTIVE The purpose of this study was to explore the research status, hot spots and trends regarding the influence of the immune system on OP and to provide a basis for research directions and applications in this field. METHODS We searched and collected literature about the immune system and OP published from 2012 to 2022 in the Web of Science Core Collection database. All the included studies were subjected to bibliometrics analysis using Hiplot Pro, VOSviewer and CiteSpace software to produce statistics and visual analyses of the literature output, countries, institutions, authors, keywords and journals. RESULTS A total of 1201 papers were included, and the number of citations of these articles reached 31,776. The number of publications and citations on the immune system and OP has increased year by year. The top three countries with the greatest number of papers published were China, the United States of America (USA) and Italy. The two institutions with the largest number of papers published were Sichuan University and Soochow University, both located in China. De Martinis Massimo (Italy) and Ginaldi Lia (Italy) are prolific authors in this field. The representative academic journals are Osteoporosis International, Frontiers in Immunology, Journal of Bone and Mineral Research, PloS One and Bone. The results of the keyword cooccurrence analysis showed that the research topics in this field mainly focused on T cells, cytokines, signaling pathways, vitamin D, postmenopausal OP and immune diseases. The keyword burst results showed that zoledronic acid, chain fatty acids and gut microbiota are the frontiers and trends of future research on this topic. CONCLUSION The influence of the immune system on OP has been widely studied, and the current research in this field focuses on the effect or mechanism of immune-related cytokines, signaling pathways and vitamin D on OP. Future research trends in this field should focus on the immune regulation mechanism and clinical transformation of zoledronic acid, chain fatty acids and the gut microbiota in OP.
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Affiliation(s)
- Jinlong Zhao
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
| | - Yaoxing Dou
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
| | - Guihong Liang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
| | - Hetao Huang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
| | - Kunhao Hong
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- Guangdong Second Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, 510095, China
| | - Weiyi Yang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
| | - Guanghui Zhou
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Bangxin Sha
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Jun Liu
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- Guangdong Second Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, 510095, China
| | - Lingfeng Zeng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, 510120, China
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13
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Sasaki H, Umezawa N, Itakura T, Iwai H, Yasuda S. Pathogenicity of functionally activated PD-1 +CD8 + cells and counterattacks by muscular PD-L1 through IFNγ in myositis. J Autoimmun 2024; 142:103131. [PMID: 37931332 DOI: 10.1016/j.jaut.2023.103131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/30/2023] [Accepted: 10/12/2023] [Indexed: 11/08/2023]
Abstract
Programmed-cell-death 1 (PD-1) expression is associated not only with T-cell activation but with exhaustion. Specifically, PD-1+ T cells present an exhausted phenotype in conditions of chronic antigen exposure, such as tumor microenvironments and chronic viral infection. However, the immune status regarding exhaustion of PD-1+CD8+ T cells in chronic autoimmune diseases including idiopathic inflammatory myopathies (IIMs) remains unclear. We aimed to clarify the role of PD-1+CD8+ T cells and PD-1 ligand (PD-L1) in IIMs. We showed that PD-1+ cells infiltrated into PD-L1-expressing muscles in patients with IIMs and immune checkpoint inhibitor-related myopathy. According to the peripheral blood immunophenotyping, the PD-1+CD8+ cell proportions were comparable between the active and inactive patients. Of note, PD-1+CD8+ cells in the active patients highly expressed cytolytic molecules, indicating their activation, while PD-1-CD8+ cells expressed low levels of cytolytic molecules in the active and inactive patients. A part of PD-1+CD8+ cells expressed the HMG-box transcription factor TOX highly and presented the exhausted phenotype in the active patients. Among PD-1+CD4+ T cells, PD-1highCXCR5-CD45RO+CD4+ peripheral helper T cells were increased in the active patients. PD-L1-deficient mice developed severer C-protein-induced myositis (CIM), a model of polymyositis, with abundant infiltration of PD-1+CD8+ cells expressing cytolytic molecules than wild-type mice, indicating pathogenicity of the PD-1+CD8+ cells and the protective role of PD-L1. The deficiency of IFNγ, a general PD-L1-inducer, impaired muscular PD-L1 expression and exacerbated CIM, indicating IFNγ-dependent muscular PD-L1 regulation. IFNγ-induced PD-L1 on myotubes was protective in an established muscle injury model. In conclusion, PD-1+CD8+ T cells rather than PD-1-CD8+ T cells were a pathogenic subset of IIMs. Muscular PD-L1 was regulated by IFNγ and exerted protective properties in IIMs.
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Affiliation(s)
- Hirokazu Sasaki
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Natsuka Umezawa
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takuji Itakura
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hideyuki Iwai
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Shinsuke Yasuda
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.
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14
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Nelke C, Pawlitzki M, Kerkhoff R, Schroeter CB, Aktas O, Neuen-Jacob E, Polzin A, Meuth SG, Ruck T. Immune Checkpoint Inhibition-Related Myasthenia-Myositis-Myocarditis Responsive to Complement Blockade. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200177. [PMID: 37884388 PMCID: PMC10602369 DOI: 10.1212/nxi.0000000000200177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/05/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but come with immune-related adverse events (irAEs) that provide a novel challenge for treating physicians. Neuromuscular irAEs, including myositis, myasthenia gravis (MG), and demyelinating polyradiculoneuropathy, lead to significant morbidity and mortality. METHODS We present a case of severe myasthenia-myositis-myocarditis overlap in a patient receiving ICIs for breast cancer. Clinical findings were recorded. RESULTS A 47-year-old woman developed tetraparesis, dysphagia, and muscle pain during ICI treatment. MG with a thymoma had been diagnosed earlier. Neuromuscular overlap irAEs with cardiac affection was confirmed, and ICI treatment was discontinued. Given a lack of clinical response to standard therapies, a muscle biopsy was performed demonstrating complement deposition. Eculizumab treatment led to rapid improvement in muscle strength and cardiac function. DISCUSSION Neuromuscular irAEs are associated with a high in-hospital mortality, and specific treatment strategies remain an unmet need. Here, early muscle biopsy enabled targeted therapy after standard approaches failed, thereby highlighting the value of identifying a specific treatment target. To improve therapeutic outcomes, the development of patient-tailored strategies for neuromuscular irAEs requires further studies.
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Affiliation(s)
- Christopher Nelke
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Marc Pawlitzki
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Ruth Kerkhoff
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Christina B Schroeter
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Orhan Aktas
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Eva Neuen-Jacob
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Amin Polzin
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Sven G Meuth
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Tobias Ruck
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany.
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15
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Mammen AL. Paraneoplastic myopathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:327-332. [PMID: 38494286 DOI: 10.1016/b978-0-12-823912-4.00022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
This chapter reviews the association between cancer and the idiopathic inflammatory myopathies (IIM), which includes dermatomyositis (DM), antisynthetase syndrome (ASyS), immune-mediated necrotizing myopathy (IMNM), and inclusion body myositis (IBM). Accumulating evidence shows that the risk of a coexisting malignancy is high in patients with DM, especially among those with anti-Tif1γ autoantibodies. Patients with IMNM and no defined autoantibodies also have an increased risk of malignancy. Recent evidence demonstrates that many IBM patients have increased numbers of circulating CD57+ CD8+ T cells, consistent with a diagnosis of large granular lymphocytic leukemia. In contrast, IMNM patients with anti-SRP or anti-HMGCR autoantibodies as well as patients with ASyS syndrome do not have a definitively increased risk of cancer. Patients who have a cancer treated with one of the immune checkpoint inhibitors can develop myositis (ICI-myositis), sometimes along with myasthenia gravis and/or myocarditis.
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Affiliation(s)
- Andrew L Mammen
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, United States; Departments of Neurology and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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16
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Yamamoto S, Yoshida A, Gono T, Kuwana M. The Role of Environmental Factors in the Development of Idiopathic Inflammatory Myopathies: a Narrative Review. Curr Rheumatol Rep 2023; 25:264-275. [PMID: 37971581 DOI: 10.1007/s11926-023-01120-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW This review aims to evaluate recent findings on the role of environmental factors in the development and clinical presentation of idiopathic inflammatory myopathies (IIMs). RECENT FINDINGS A targeted literature review was conducted to identify reports relevant to the association between environmental factors and IIMs published over the past three years. There has been an increasing number of publications dealing with the association of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or vaccination with the development of IIMs, highlighting the significant role of the antiviral immune response in the pathogenesis of the disease. Traditional environmental factors associated with the pathogenic process of IIM subclassifications included drugs such as statins and immune checkpoint inhibitors, ultraviolet radiation, smoking, air pollutants, and vitamin D deficiency. Correlations of seasonality and residence with the onset of certain IIM subtypes suggest a potential role of environmental triggers in the pathogenic process. An interplay between genetic predisposition and various environmental factors might contribute to the development of IIMs as well as the heterogeneous clinical and serological presentation of IIMs. The growing evidence on the role of environmental factors in the development of IIMs provides important clues to elucidate the pathophysiology of these disease entities. The mechanisms underlying the interactions between genetic predisposition and environmental factors should be investigated in the future.
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Affiliation(s)
- Shintaro Yamamoto
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Akira Yoshida
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan.
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan.
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17
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Fenioux C, Abbar B, Boussouar S, Bretagne M, Power JR, Moslehi JJ, Gougis P, Amelin D, Dechartres A, Lehmann LH, Courand PY, Cautela J, Alexandre J, Procureur A, Rozes A, Leonard-Louis S, Qin J, Cheynier R, Charmeteau-De Muylder B, Redheuil A, Tubach F, Cadranel J, Milon A, Ederhy S, Similowski T, Johnson DB, Pizzo I, Catalan T, Benveniste O, Hayek SS, Allenbach Y, Rosenzwajg M, Dolladille C, Salem JE. Thymus alterations and susceptibility to immune checkpoint inhibitor myocarditis. Nat Med 2023; 29:3100-3110. [PMID: 37884625 DOI: 10.1038/s41591-023-02591-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/15/2023] [Indexed: 10/28/2023]
Abstract
Immune checkpoint inhibitors (ICI) have transformed the therapeutic landscape in oncology. However, ICI can induce uncommon life-threatening autoimmune T-cell-mediated myotoxicities, including myocarditis and myositis. The thymus plays a critical role in T cell maturation. Here we demonstrate that thymic alterations are associated with increased incidence and severity of ICI myotoxicities. First, using the international pharmacovigilance database VigiBase, the Assistance Publique Hôpitaux de Paris-Sorbonne University data warehouse (Paris, France) and a meta-analysis of clinical trials, we show that ICI treatment of thymic epithelial tumors (TET, and particularly thymoma) was more frequently associated with ICI myotoxicities than other ICI-treated cancers. Second, in an international ICI myocarditis registry, we established that myocarditis occurred earlier after ICI initiation in patients with TET (including active or prior history of TET) compared to other cancers and was more severe in terms of life-threatening arrythmias and concurrent myositis, leading to respiratory muscle failure and death. Lastly, we show that presence of anti-acetylcholine-receptor antibodies (a biological proxy of thymic-associated autoimmunity) was more prevalent in patients with ICI myocarditis than in ICI-treated control patients. Altogether, our results highlight that thymic alterations are associated with incidence and seriousness of ICI myotoxicities. Clinico-radio-biological workup evaluating the thymus may help in predicting ICI myotoxicities.
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Affiliation(s)
- Charlotte Fenioux
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
- Hôpitaux de Paris, Henri Mondor Hospital, Department of Oncology, Créteil, France
| | - Baptiste Abbar
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Department of Oncology, Paris, France
| | - Samia Boussouar
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Department of Radiology, Paris, France
| | - Marie Bretagne
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
| | - John R Power
- Department of Medecine, University of California, San Diego, San Diego, CA, USA
| | - Javid J Moslehi
- Department of Medecine, University of California, San Francisco, San Francisco, CA, USA
| | - Paul Gougis
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
| | - Damien Amelin
- Sorbonne Université, INSERM, Association Institut de Myologie, Center of Research in Myology, UMRS 974, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Lorenz H Lehmann
- Department of Cardiology, University Hospital Heidelberg; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Pierre-Yves Courand
- Fédération de Cardiologie, IMMUCARE, Hôpital de La Croix-Rousse Et Hôpital Lyon Sud, Hospices Civils de Lyon; Université de Lyon, CREATIS UMR INSERM U1044, INSA, Lyon, France
| | - Jennifer Cautela
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, INSERM 1263, INRAE 1260, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Paris, France
| | - Joachim Alexandre
- CHU de Caen Normandie, Department of Pharmacology, Pharmacoepidemiology Unit; Normandie Université, UNICAEN, INSERM U1086 ANTICIPE Centre François Baclesse, Caen, France
| | - Adrien Procureur
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
| | - Antoine Rozes
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Sarah Leonard-Louis
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Laboratoire de Neuropathologie, Paris, France
| | - Juan Qin
- Department of Medecine, University of California, San Francisco, San Francisco, CA, USA
| | - Rémi Cheynier
- Université Paris Cité, CNRS, INSERM, Institut Cochin, Paris, France
| | | | - Alban Redheuil
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Department of Radiology, Paris, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Jacques Cadranel
- Hôpitaux de Paris, Tenon Hospital, Department of Pulmonology and Thoracic Oncology and GRC Theranoscan Sorbonne University, Paris, France
| | - Audrey Milon
- Hôpitaux de Paris, Tenon Hospital, Department of Radiology, Paris, France
| | - Stéphane Ederhy
- Hôpitaux de Paris, Saint-Antoine Hospital, Department of Cardiology, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS 1158 Neurophysiologie respiratoire expérimentale et clinique'; Assistance Publique -Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 'Département R3S', Paris, France
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ian Pizzo
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Toniemarie Catalan
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Olivier Benveniste
- Department of Internal Medicine, Sorbonne University, AP-HP, INSERM UMRS 974, Pitié-Salpêtrière Hospital, Paris, France
| | - Salim S Hayek
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Yves Allenbach
- Department of Internal Medicine, Sorbonne University, AP-HP, INSERM UMRS 974, Pitié-Salpêtrière Hospital, Paris, France
| | - Michelle Rosenzwajg
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Department of Immunology, Paris, France
| | - Charles Dolladille
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
| | - Joe-Elie Salem
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France.
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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18
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Zhao M, Mi L, Ji Y, He X, Gao Y, Hu Y, Xu K. Advances of autoimmune rheumatic diseases related to malignant tumors. Inflamm Res 2023; 72:1965-1979. [PMID: 37768354 PMCID: PMC10611618 DOI: 10.1007/s00011-023-01780-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/30/2023] [Accepted: 08/04/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Malignant neoplasms are a well-recognized global public health concern, with significant impacts on human health and quality of life. The interplay between tumors and autoimmune rheumatic diseases is complex, and the resulting tumor-associated rheumatic diseases represent a rare and intricate group of conditions that occur in the context of malignant tumors. In addition, various rheumatic diseases can arise as a consequence of oncology treatment. These diseases present with intricate clinical manifestations and pathological features, often rendering them challenging to diagnose and impacting patients' quality of life. Despite this, they have yet to be fully recognized. METHODS This article presents a literature review of published original articles and review articles concerning paraneoplastic rheumatic syndromes and rheumatic diseases associated with cancer treatment. We conducted a comprehensive literature search in PubMed, Web of Science and Google Scholar databases, excluding duplicated and irrelevant studies. In cases of duplicated research, we selected articles with higher impact factors for the review. RESULTS This review focuses on the clinical features, diagnosis, and treatment of paraneoplastic rheumatic diseases, as well as the pathogenesis of these diseases. Additionally, we summarize the autoimmune rheumatic diseases associated with cancer treatment. Ultimately, the goal of this review is to enhance recognition and improve the management of autoimmune rheumatic diseases related to tumors.
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Affiliation(s)
- Miaomiao Zhao
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Liangyu Mi
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Yuli Ji
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Xiaoyao He
- Department of Statistics, School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Yanan Gao
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Yuting Hu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Ke Xu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China.
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19
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Wang C, Zhao G, Zhang Z, Yang L, Liu S, Li G, Wang H, Huang J, Wang S, Li N. Immune checkpoint inhibitor-associated myocarditis: a systematic analysis of case reports. Front Immunol 2023; 14:1275254. [PMID: 37876928 PMCID: PMC10590906 DOI: 10.3389/fimmu.2023.1275254] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/22/2023] [Indexed: 10/26/2023] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) therapy can be complicated by their potential cardiovascular toxicities, including myocarditis. Nowadays, no prospective trials have focused on ICI-associated myocarditis optimized management. Available evidence only come from case reports or series. A systematic case reports analysis was conducted to collect and evaluate emerging evidence of ICI-associated myocarditis to provide more information to clinicians. Methods We performed a literature search for eligible case reports or series published between January 2018 and May 2023 using the PubMed database. Then, we extracted interesting information via table form. Finally, this study included 113 publications on 106 patients with ICI-associated myocarditis. Results Myocarditis was found to be a highly life-threatening disease, with 53.8% of cases. Over half of cases were life-threatening (G4, 23.6%) or severe (G3, 35.8%) and required glucocorticoids. Higher rates of improvement were associated with the best response to ICI for complete response/partial response (72.7% vs. 53.9%), glucocorticoid administration (30% vs. 22%), and discontinuation of ICI (58.8% vs. 32.1%). Consequently, ICI-associated G3-G4 myocarditis should be treated with a combination of discontinuation of ICIs, high-dose glucocorticoids, other drugs, chemical drugs, plasma exchange, and life support. For moderate G1 or G2 cases, discontinuation of ICIs and regular-dose glucocorticoids should be considered. Conclusion Once full recovery or improvement was achieved; glucocorticoids can be administered at low doses or stopped. Notably, re-challenge with ICIs appears feasible after resolution or meaningful improvement of myocarditis.
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Affiliation(s)
- Caie Wang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Guo Zhao
- Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhen Zhang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Lukui Yang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Shihao Liu
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Guifang Li
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Hongxia Wang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Jiaxin Huang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Shuhang Wang
- Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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20
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Lehmann LH, Heckmann MB, Bailly G, Finke D, Procureur A, Power JR, Stein F, Bretagne M, Ederhy S, Fenioux C, Hamwy O, Funck-Brentano E, Romano E, Pieroni L, Münster J, Allenbach Y, Anquetil C, Leonard-Louis S, Palaskas NL, Hayek SS, Katus HA, Giannitsis E, Frey N, Kaya Z, Moslehi J, Prifti E, Salem JE. Cardiomuscular Biomarkers in the Diagnosis and Prognostication of Immune Checkpoint Inhibitor Myocarditis. Circulation 2023; 148:473-486. [PMID: 37317858 PMCID: PMC10527069 DOI: 10.1161/circulationaha.123.062405] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/19/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are approved for multiple cancers but can result in ICI-associated myocarditis, an infrequent but life-threatening condition. Elevations in cardiac biomarkers, specifically troponin-I (cTnI), troponin-T (cTnT), and creatine kinase (CK), are used for diagnosis. However, the association between temporal elevations of these biomarkers with disease trajectory and outcomes has not been established. METHODS We analyzed the diagnostic accuracy and prognostic performances of cTnI, cTnT, and CK in patients with ICI myocarditis (n=60) through 1-year follow-up in 2 cardio-oncology units (APHP Sorbonne, Paris, France and Heidelberg, Germany). A total of 1751 (1 cTnT assay type), 920 (4 cTnI assay types), and 1191 CK sampling time points were available. Major adverse cardiomyotoxic events (MACE) were defined as heart failure, ventricular arrhythmia, atrioventricular or sinus block requiring pacemaker, respiratory muscle failure requiring mechanical ventilation, and sudden cardiac death. Diagnostic performance of cTnI and cTnT was also assessed in an international ICI myocarditis registry. RESULTS Within 72 hours of admission, cTnT, cTnI, and CK were increased compared with upper reference limits (URLs) in 56 of 57 (98%), 37 of 42 ([88%] P=0.03 versus cTnT), and 43 of 57 ([75%] P<0.001 versus cTnT), respectively. This increased rate of positivity for cTnT (93%) versus cTnI ([64%] P<0.001) on admission was confirmed in 87 independent cases from an international registry. In the Franco-German cohort, 24 of 60 (40%) patients developed ≥1 MACE (total, 52; median time to first MACE, 5 [interquartile range, 2-16] days). The highest value of cTnT:URL within the first 72 hours of admission performed best in terms of association with MACE within 90 days (area under the curve, 0.84) than CK:URL (area under the curve, 0.70). A cTnT:URL ≥32 within 72 hours of admission was the best cut-off associated with MACE within 90 days (hazard ratio, 11.1 [95% CI, 3.2-38.0]; P<0.001), after adjustment for age and sex. cTnT was increased in all patients within 72 hours of the first MACE (23 of 23 [100%]), whereas cTnI and CK values were less than the URL in 2 of 19 (11%) and 6 of 22 (27%) of patients (P<0.001), respectively. CONCLUSIONS cTnT is associated with MACE and is sensitive for diagnosis and surveillance in patients with ICI myocarditis. A cTnT:URL ratio <32 within 72 hours of diagnosis is associated with a subgroup at low risk for MACE. Potential differences in diagnostic and prognostic performances between cTnT and cTnI as a function of the assays used deserve further evaluation in ICI myocarditis.
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Affiliation(s)
- Lorenz H. Lehmann
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Markus B. Heckmann
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Guillaume Bailly
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Daniel Finke
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Adrien Procureur
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - John R. Power
- University of California San Diego, San Diego, California, USA
| | - Frederic Stein
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Marie Bretagne
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Stephane Ederhy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris,, INSERM, Department of Cardiology, CIC-1901, UNICO-GRECO Cardio-oncology program, Saint-Antoine Hospital, Paris, France
| | - Charlotte Fenioux
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Omar Hamwy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | | | - Emanuela Romano
- Center for Cancer Immunotherapy, Department of Oncology, PSL Research University, Institut Curie, Paris, France
| | - Laurence Pieroni
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Biochimie- Hormonologie, Hôpital Tenon, Paris, France
| | - Jan Münster
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Yves Allenbach
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of internal medecine, Hôpital Pitié-Salpêtrière, Paris, France
| | - Céline Anquetil
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of internal medecine, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sarah Leonard-Louis
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Neuropathology, Hôpital Pitié-Salpêtrière, F-75013 Paris, France
| | - Nicolas L. Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | | | - Salim S. Hayek
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI
| | - Hugo A. Katus
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Ziya Kaya
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Javid Moslehi
- Section of Cardio-Oncology & Immunology, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Edi Prifti
- IRD, Sorbonne University, UMMISCO, 32 Avenue Henri Varagnat, F-93143 Bondy, France; Sorbonne Université, INSERM (NutriOmics), Paris, France
| | - Joe-Elie Salem
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
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21
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Tanboon J, Needham M, Mozaffar T, Stenzel W, Nishino I. Editorial: Inflammatory muscle diseases: an update. Front Neurol 2023; 14:1259275. [PMID: 37614973 PMCID: PMC10442951 DOI: 10.3389/fneur.2023.1259275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023] Open
Affiliation(s)
- Jantima Tanboon
- Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Merrilee Needham
- University of Notre Dame Australia, Fremantle, WA, Australia
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
- Department of Neurology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Tahseen Mozaffar
- Department of Neurology, School of Medicine, University of California, Irvine, Irvine, CA, United States
- Pathology and Laboratory Medicine, School of Medicine, University of California, Irvine, Irvine, CA, United States
- School of Medicine, The Institute for Immunology, University of California, Irvine, Irvine, CA, United States
| | - Werner Stenzel
- Department of Neuropathology, Berlin Institute of Health (BIH), Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
- Department of Genome Medicine Development, Medical Genome Center, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
- Department of Clinical Genome Analysis, Medical Genome Center, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
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22
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Curkovic NB, Johnson DB. Updates in toxicities associated with immune checkpoint inhibitors. Expert Rev Clin Immunol 2023; 19:1117-1129. [PMID: 37276071 PMCID: PMC10527235 DOI: 10.1080/1744666x.2023.2221434] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/31/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have become a pillar of treatment for numerous cancers with increasing use in combination with other ICIs and in earlier stages of disease treatment. Although effective, ICI use is accompanied by a milieu of potentially bothersome or even life-threatening toxicities known as immune-related adverse events (irAEs), necessitating careful monitoring and early intervention. AREAS COVERED In this review, we provide an overview of recent advances surrounding toxicity pathophysiology and treatment in the context of relevant organ systems. An emphasis on current treatments by toxicity, as well as updates on steroid-refractory toxicities, chronic toxicities, and biomarkers will be a focus of this update on the current understanding of irAEs. EXPERT OPINION ICI toxicities are a major limitation on the deployment of multi-agent ICI regimens and are thus a major priority to understand, treat, and prevent. Recent developments have led to greater understanding of the pathophysiology of these events, which may lead to improved prevention or mitigation strategies. Further, early studies have also suggested steroid-sparing approaches that may be useful. Ultimately, preventing and managing irAEs will be a key goal toward successful ICI treatment across a broader range of patients with cancer.
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Affiliation(s)
| | - Douglas B. Johnson
- Department of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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23
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Giovannini E, Bonasoni MP, D'Aleo M, Tamagnini I, Tudini M, Fais P, Pelotti S. Pembrolizumab-Induced Fatal Myasthenia, Myocarditis, and Myositis in a Patient with Metastatic Melanoma: Autopsy, Histological, and Immunohistochemical Findings-A Case Report and Literature Review. Int J Mol Sci 2023; 24:10919. [PMID: 37446095 DOI: 10.3390/ijms241310919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) represent a major advance in cancer treatment. The lowered immune tolerance induced by ICIs brought to light a series of immune-related adverse events (irAEs). Pembrolizumab belongs to the ICI class and is a humanized IgG4 anti-PD-1 antibody that blocks the interaction between PD-1 and PD-L1. The ICI-related irAEs involving various organ systems and myocarditis are uncommon (incidence of 0.04% to 1.14%), but they are associated with a high reported mortality. Unlike idiopathic inflammatory myositis, ICI-related myositis has been reported to frequently co-occur with myocarditis. The triad of myasthenia, myositis, and myocarditis must not be underestimated as they can rapidly deteriorate, leading to death. Herein we report a case of a patient with metastatic melanoma who fatally developed myasthenia gravis, myocarditis, and myositis, after a single cycle of pembrolizumab. Considering evidence from the literature review, autopsy, histological, and immunohistochemical investigations on heart and skeletal muscle are presented and discussed, also from a medical-legal perspective.
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Affiliation(s)
- Elena Giovannini
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Maria Paola Bonasoni
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Michele D'Aleo
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Ione Tamagnini
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Matteo Tudini
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Paolo Fais
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Susi Pelotti
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
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Yamanaka T, Takemura K, Hayashida M, Suyama K, Urakami S, Miura Y. Cabozantinib-induced serum creatine kinase elevation and rhabdomyolysis: a retrospective case series. Cancer Chemother Pharmacol 2023:10.1007/s00280-023-04557-0. [PMID: 37380798 DOI: 10.1007/s00280-023-04557-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/13/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE Rhabdomyolysis, which is primarily characterized by serum creatine kinase (CK) elevation, is a potentially fatal disease, and it can occur in a variety of etiologies, including drug-induced. Cabozantinib is one of the standard treatments for patients with renal cell carcinoma (RCC). This retrospective case series aimed to investigate the frequency of cabozantinib-induced CK elevation and rhabdomyolysis, and to reveal their detailed clinical features. METHODS To investigate the frequency of cabozantinib-induced serum CK elevation and rhabdomyolysis, we retrospectively reviewed the clinical information and laboratory data of the patients with advanced RCC who received cabozantinib monotherapy at our institution from April 2020 to April 2023. Data were retrieved from the electronic medical records and the RCC database of our institution. Primary endpoint of the current case series was the frequency of CK elevation and rhabdomyolysis. RESULTS Sixteen patients were retrieved form the database and 13 were included in the case series (excluded by clinical trial enrollment [n = 2] and short-term administration [n = 1]). Eight (61.5%) patients among them experienced serum CK elevation, including five patients who were classified into grade 1. CK elevation occurred a median of 14 days after initiation of cabozantinib. Two patients with grade 2 or 3 of CK elevation developed rhabdomyolysis with muscle weakness and/or acute kidney injury. CONCLUSIONS CK elevation may frequently happen during cabozantinib treatment, and in most cases, it may be asymptomatic and may not be clinically problematic. However, medical providers should be aware that symptomatic CK elevations suggestive of rhabdomyolysis may occasionally occur.
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Affiliation(s)
- Taro Yamanaka
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | - Kohji Takemura
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | | | - Koichi Suyama
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | | | - Yuji Miura
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan.
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Abstract
PURPOSE OF REVIEW Immune check point inhibitors (ICIs) are a unique class of cancer treatments that harness the body's innate antitumor response. Although these medications have transformed oncology care, they also lead to generalized immune activation that can result in toxicities across a spectrum of organ systems called immune-related adverse events. This article reviews the most common rheumatologic immune-related adverse events and their management. RECENT FINDINGS Inflammatory arthritis, polymyalgia rheumatic, sicca symptoms, systemic sclerosis, myositis, and vasculitis have all been reported as ICI adverse events. Treatment includes nonsteroidal anti-inflammatory drugs, glucocorticoids, traditional DMARDs, and biologics. SUMMARY Rheumatologists have an important role in the management of patients with rheumatologic immune-related adverse events. Working with our oncology colleagues, we can help manage rheumatologic immune-related adverse events while optimally preserving ICI's antitumor effects.
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Affiliation(s)
- Melissa Defoe
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Rheumatic Immune-Related Adverse Events due to Immune Checkpoint Inhibitors—A 2023 Update. Int J Mol Sci 2023; 24:ijms24065643. [PMID: 36982715 PMCID: PMC10051463 DOI: 10.3390/ijms24065643] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/05/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
With the aging of the population, malignancies are becoming common complications in patients with rheumatoid arthritis (RA), particularly in elderly patients. Such malignancies often interfere with RA treatment. Among several therapeutic agents, immune checkpoint inhibitors (ICIs) which antagonize immunological brakes on T lymphocytes have emerged as a promising treatment option for a variety of malignancies. In parallel, evidence has accumulated that ICIs are associated with numerous immune-related adverse events (irAEs), such as hypophysitis, myocarditis, pneumonitis, and colitis. Moreover, ICIs not only exacerbate pre-existing autoimmune diseases, but also cause de novo rheumatic disease–like symptoms, such as arthritis, myositis, and vasculitis, which are currently termed rheumatic irAEs. Rheumatic irAEs differ from classical rheumatic diseases in multiple aspects, and treatment should be individualized based on the severity. Close collaboration with oncologists is critical for preventing irreversible organ damage. This review summarizes the current evidence regarding the mechanisms and management of rheumatic irAEs with focus on arthritis, myositis, and vasculitis. Based on these findings, potential therapeutic strategies against rheumatic irAEs are discussed.
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Zekić T, Benić MS. Anti-programmed death-1 inhibitor nivolumab-induced immune-related adverse events: hepatitis, renal insufficiency, myositis, vitiligo, and hypothyroidism: a case-based review. Rheumatol Int 2023; 43:559-565. [PMID: 36449057 DOI: 10.1007/s00296-022-05247-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/09/2022] [Indexed: 12/03/2022]
Abstract
Nivolumab (NIVO) is a monoclonal antibody used to treat renal cell cancer. It is an anti-programmed death-1 (anti-PD-1) inhibitor, enhancing the tumor-targeted immune response of T lymphocytes, resulting in immune-mediated adverse events (AEs). We present five immunological AEs in a single patient treated with NIVO. A 68-year-old male patient with metastatic renal cell carcinoma and right-sided nephrectomy received NIVO after pazopanib and sunitinib treatment. Two and a half months after starting NIVO, hepatocellular enzymes and creatinine were elevated. Concomitantly, the patient noticed hypopigmentation of the hand skin and a change in voice and speech. Due to hepatitis, he has been treated with dexamethasone 16 mg daily for 22 days, after which hypothyroidism and increased creatine kinase were found without muscle pain and functional impairment. Dexamethasone was continued, and a rapid decline in all parameters except thyroid-stimulating hormone (TSH) and vitiligo was observed. Myositis was initially considered a part of hypothyroidism and elevated renal parameters due to hypohydration. The rapid regression on glucocorticoid treatment and a longer time for creatinine normalization than expected with hydration were noticed. Nivolumab likely induced those side effects as assessed by Naranjo Adverse Drug Reaction Probability Scale. The literature review shows that the consequences of PD-1 inhibition are not uniform. Side effects of checkpoint inhibitors should be monitored carefully in the early and later treatment schedules evaluating subclinical manifestations like myositis and worsening of kidney parameters. Early administered higher doses of glucocorticoids can stop drug toxicity and reverse-induced tissue damage.
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Affiliation(s)
- Tatjana Zekić
- Faculty of Medicine, Clinical Hospital Center Rijeka, Department of Rheumatology and Clinical Immunology, University of Rijeka, Rijeka, Croatia.
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Galluzzo C, Chiapparoli I, Corrado A, Cantatore FP, Salvarani C, Pipitone N. Rare forms of inflammatory myopathies - part I, generalized forms. Expert Rev Clin Immunol 2023; 19:169-183. [PMID: 36469633 DOI: 10.1080/1744666x.2023.2154656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The idiopathic inflammatory myopathies traditionally comprise dermatomyositis, polymyositis, immune-mediated necrotizing myopathy, anti-synthetase syndrome, and inclusion body myositis. In this review, we aimed to cover the less common forms of generalized myositis. AREAS COVERED We identified rare forms of widespread myositis on the basis of list provided by the homepage of the Neuromuscular disease center of Washington University, USA and on the basis of the authors' knowledge. We searched PubMed® and EMBASE® for relevant articles on these forms with the aim of providing as much as possible information on their clinical manifestations as well as guidance on their work-up and treatment. EXPERT OPINION There is substantial heterogeneity among the various rare forms of generalized myositis in terms of their frequency and characterization. Some forms are reasonably well defined, while others may not represent truly well-defined diseases, but rather variants of other myopathies. The landscape of rare forms appears to have evolved over time, with some forms now being better characterized, while others, such as SARS-Cov-2- and immune checkpoint inhibitor-related myositis have come to the fore only in recent years. Knowledge about rare forms of myositis can aid in their recognition and treatment.
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Affiliation(s)
- Claudio Galluzzo
- Department of internal Medicine, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ilaria Chiapparoli
- Department of internal Medicine, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ada Corrado
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Francesco Paolo Cantatore
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Carlo Salvarani
- Department of internal Medicine, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Università di Modena e Reggio Emilia, Modena, Italy
| | - Nicolò Pipitone
- Department of internal Medicine, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Grümme L, Schulze-Koops H. [Rheumatological side effects of checkpoint inhibitors and their treatment]. Z Rheumatol 2023; 82:187-194. [PMID: 36607420 DOI: 10.1007/s00393-022-01311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/07/2023]
Abstract
The spectrum of tumors for which checkpoint inhibitor (CI) treatment is used is constantly expanding. The European Medicines Agency has currently approved nine CIs: one anti-cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) CI, one anti-lymphocyte activation gene 3 (LAG-3) CI, four anti-programmed cell death protein 1 (PD-1) CIs and three anti-programmed death ligand 1 (PD-L1) CIs. By blocking immune checkpoints the physiological downregulation of T cell activity against autologous tissue is prevented. This results in an immunologically unregulated activation of T cells directed against malignant cells. Healthy tissue also expresses antigens and thereby continuously activates autologous T cells. Thus, the blockade of immune checkpoints can lead to T cell activity against healthy tissue (immune-related adverse events, irAE). The irAEs can occur in any organ system and approximately 10% of all patients under CI treatment develop rheumatological irAEs, mostly arthralgia and myalgia. The classification criteria of rheumatological diseases do not need to be met to initiate treatment and the primary goal of treatment of irAEs is to enable continuation of CI treatment. Rheumatological irAEs should be recognized and treated quickly. In the treatment of musculoskeletal irAEs, three stages can be defined. In the first stage, nonsteroidal anti-inflammatory drugs or intra-articular as well as systemic glucocorticoids are used. In the second stage, conventional synthetic and in the third stage, biologic disease-modifying antirheumatic drugs are used. The most severe musculoskeletal irAE is myositis with cardiac and/or respiratory involvement and/or myasthenia gravis. In addition to high-dose glucocorticoids, intravenous immunoglobulins or plasma exchange are used in treatment.
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Affiliation(s)
- Lea Grümme
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| | - Hendrik Schulze-Koops
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
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30
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Erritzøe-Jervild M, Scheie D, Stenør C. Checkpoint inhibitor induced myositis - The value of MRI STIR. eNeurologicalSci 2023; 30:100442. [PMID: 36683900 PMCID: PMC9849862 DOI: 10.1016/j.ensci.2022.100442] [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: 10/28/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 01/05/2023] Open
Abstract
•Treatment with immune checkpoint inhibitors can cause serious adverse events.•Myositis combined with myocarditis ad adverse event have a mortality for 50%.•Early diagnosis is important for better outcome.•Employing MRI STIR can rapidly diagnose, guide biopsy, and classify cases of immune-related myositis.
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Affiliation(s)
- Mai Erritzøe-Jervild
- Department of Neurology, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark,Corresponding author at: Department of Neurology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark.
| | - David Scheie
- Department of Pathology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Christian Stenør
- Department of Neurology, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark
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31
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Reid P, Cappelli LC. Treatment of rheumatic adverse events of cancer immunotherapy. Best Pract Res Clin Rheumatol 2022; 36:101805. [PMID: 36539321 PMCID: PMC10198805 DOI: 10.1016/j.berh.2022.101805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Immune checkpoint inhibitors (ICIs), used to treat many advanced cancers, activate the immune system to elicit an antitumor response. ICIs can also cause immune-related adverse events (irAEs) when nontumor tissues are affected by excess inflammation and autoimmunity. Rheumatic irAEs include inflammatory arthritis, myositis, sicca syndrome, polymyalgia rheumatica, and several other rare phenotypes. Treating rheumatic irAEs requires balancing the desire to decrease off-target inflammation while not negatively impacting the antitumor immune response. In this review, treatment recommendations for rheumatic irAEs have been discussed. Pathogenesis of rheumatic irAEs has been briefly reviewed. Knowledge about the effects of corticosteroids and steroid-sparing agents on tumor responses has been detailed to give context for treatment decisions. Recommendations ultimately depend not only on the clinical presentation and severity of the irAE but also on the goals of cancer treatment. Finally, how to safely use ICI therapy in patients with preexisting autoimmune diseases is considered.
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Affiliation(s)
- Pankti Reid
- University of Chicago, Department of Medicine, Section of Rheumatology, 5841 South Maryland Ave. MC 0930, Chicago, IL, 60637, USA.
| | - Laura C Cappelli
- Johns Hopkins University, Department of Medicine, Division of Rheumatology, 5501 Hopkins Bayview Circle, Suite 1B1, Baltimore, MD, 21224, USA.
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Nowatzke J, Guedeney P, Palaskas N, Lehmann L, Ederhy S, Zhu H, Cautela J, Francis S, Courand PY, Deswal A, Ewer SM, Aras M, Arangalage D, Ghafourian K, Fenioux C, Finke D, Peretto G, Zaha V, Itzhaki Ben Zadok O, Tajiri K, Akhter N, Levenson J, Baldassarre L, Power J, Huang S, Collet JP, Moslehi J, Salem JE. Coronary artery disease and revascularization associated with immune checkpoint blocker myocarditis: Report from an international registry. Eur J Cancer 2022; 177:197-205. [PMID: 36030143 PMCID: PMC10165738 DOI: 10.1016/j.ejca.2022.07.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 06/04/2022] [Accepted: 07/15/2022] [Indexed: 01/06/2023]
Abstract
PURPOSE Immune checkpoint blocker (ICB) associated myocarditis (ICB-myocarditis) may present similarly and/or overlap with other cardiac pathology including acute coronary syndrome presenting a challenge for prompt clinical diagnosis. METHODS An international registry was used to retrospectively identify cases of ICB-myocarditis. Presence of coronary artery disease (CAD) was defined as coronary artery stenosis >70% in patients undergoing coronary angiogram. RESULTS Among 261 patients with clinically suspected ICB-myocarditis who underwent a coronary angiography, CAD was present in 59/261 patients (22.6%). Coronary revascularization was performed during the index hospitalisation in 19/59 (32.2%) patients. Patients undergoing coronary revascularization less frequently received steroids administration within 24 h of admission compared to the other groups (p = 0.029). Myocarditis-related 90-day mortality was 9/17 (52.7%) in the revascularised cohort, compared to 5/31 (16.1%) in those not revascularized and 25/156 (16.0%) in those without CAD (p = 0.001). Immune-related adverse event-related 90-day mortality was 9/17 (52.7%) in the revascularized cohort, compared to 6/31 (19.4%) in those not revascularized and 31/156 (19.9%) in no CAD groups (p = 0.007). All-cause 90-day mortality was 11/17 (64.7%) in the revascularized cohort, compared to 13/31 (41.9%) in no revascularization and 60/158 (38.0%) in no CAD groups (p = 0.10). After adjustment of age and sex, coronary revascularization remained associated with ICB-myocarditis-related death at 90 days (hazard ratio [HR] = 4.03, 95% confidence interval [CI] 1.84-8.84, p < 0.001) and was marginally associated with all-cause death (HR = 1.88, 95% CI, 0.98-3.61, p = 0.057). CONCLUSION CAD may exist concomitantly with ICB-myocarditis and may portend a poorer outcome when revascularization is performed. This is potentially mediated through delayed diagnosis and treatment or more severe presentation of ICB-myocarditis.
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Affiliation(s)
- Joseph Nowatzke
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paul Guedeney
- Sorbonne Université, Department of Cardiology, INSERM UMRS_1166, Pitié Salpêtrière (AP-HP), Paris, France
| | - Nicholas Palaskas
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Lorenz Lehmann
- Department of Cardiology, University Hospital of Heidelberg, 69120, Heidelberg, Germany; Institute of Experimental Cardiology, University Hospital of Heidelberg, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg/Mannheim, Germany
| | - Stephane Ederhy
- Department of Cardiology, UNICO Cardio-Oncology Program, INSERM U 856, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Han Zhu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer Cautela
- French Institute of Health and Medical Research 1263, National Institute of Agricultural Research, Centre for CardioVascular and Nutrition Research, Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, University Mediterranean Centre of Cardio-Oncology, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Sanjeev Francis
- Cardiovascular Disease Service Line, Maine Medical Center, Portland, ME, USA
| | - Pierre-Yves Courand
- Fédération de Cardiologie, Hôpital de La Croix-Rousse et Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France; Université de Lyon, CREATIS, CNRS UMR5220, INSERM U1044, INSA-Lyon, Université Claude Bernard Lyon 1, France
| | - Anita Deswal
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Steven M Ewer
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Mandar Aras
- Division of Cardiology, University of California-San Francisco, San Francisco, CA, USA
| | - Dimitri Arangalage
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, UMRS1148, INSERM, Paris, France; Université de Paris, Paris, France
| | - Kambiz Ghafourian
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Charlotte Fenioux
- Department of Pharmacology and Clinical Investigation Centre (CIC-1901), Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, INSERM, 75013, Paris, France
| | - Daniel Finke
- Department of Cardiology, University Hospital of Heidelberg, 69120, Heidelberg, Germany; Institute of Experimental Cardiology, University Hospital of Heidelberg, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg/Mannheim, Germany
| | - Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Vlad Zaha
- Division of Cardiology, Department of Internal Medicine, Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center, Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Osnat Itzhaki Ben Zadok
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kazuko Tajiri
- Department of Cardiology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Nausheen Akhter
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joshua Levenson
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - John Power
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, CA, USA
| | - Shi Huang
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jean-Philippe Collet
- Sorbonne Université, Department of Cardiology, INSERM UMRS_1166, Pitié Salpêtrière (AP-HP), Paris, France
| | - Javid Moslehi
- Division of Cardiology, University of California-San Francisco, San Francisco, CA, USA.
| | - Joe-Elie Salem
- Department of Pharmacology and Clinical Investigation Centre (CIC-1901), Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, INSERM, 75013, Paris, France.
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Chen Y, Chen Y, Xie J, Liu D, Hong X. Multisystem immune-related adverse events due to toripalimab: Two cases-based review. Front Cardiovasc Med 2022; 9:1036603. [PMID: 36505392 PMCID: PMC9732722 DOI: 10.3389/fcvm.2022.1036603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/24/2022] [Indexed: 11/27/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have significantly improved the survival of patients with advanced tumors. However, immune-related adverse events (irAEs) caused by ICIs, especially high-grade irAEs, are of growing concern. High-grade multisystem irAEs due to toripalimab, a programmed cell death-1 (PD-1) inhibitor, have been rarely reported. Two patients with malignant metastatic tumors were treated with anti-PD-1 immunotherapy. However, both patients developed high-grade multisystem irAEs based on myocarditis, with chest discomfort and malaise as the main clinical manifestation. Both patients had an elevation of cardiac enzymes, abnormal electrocardiography and left ventricular wall motion. Patient 2 was also diagnosed with organizing pneumonia. Immunotherapy was suspended. High-dose intravenous methylprednisolone was immediately initiated. The patients' symptoms were significantly relieved in a short period of time. Immunosuppressants were discontinued at the 6th month follow-up in patient 1 without relapse. However, patient 2 was lost to follow up due to financial reasons. To the best of our knowledge, this is the first report regarding ICI-associated myocarditis-pneumonia due to toripalimab, indicating the significance of early recognition and management of high-grade multisystem irAEs in clinical practice.
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Affiliation(s)
- Yanran Chen
- The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Yulan Chen
- Department of Rheumatology and Immunology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Jingyi Xie
- Department of Rheumatology and Immunology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Dongzhou Liu
- Department of Rheumatology and Immunology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Xiaoping Hong
- The Second Clinical Medical College, Jinan University, Shenzhen, China,Department of Rheumatology and Immunology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen, China,*Correspondence: Xiaoping Hong, , orcid.org/0000-0002-2062-8394
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Yin B, Xiao J, Wang X, Li X, Guan Y, Chen J, Han P, Li K, Wang J. Myocarditis and myositis/myasthenia gravis overlap syndrome induced by immune checkpoint inhibitor followed by esophageal hiatal hernia: A case report and review of the literature. Front Med (Lausanne) 2022; 9:950801. [DOI: 10.3389/fmed.2022.950801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022] Open
Abstract
Immunotherapy with programmed death 1 (PD-1) inhibitor has shown activity as first- or second-line treatment for various metastatic human malignancies. Immune-related adverse events (irAEs) are now well-described, and most organ sites are potentially influenced, but the prevalence of myocarditis and myositis/myasthenia gravis (MG) overlap syndrome following esophageal hiatal hernia induced by immunotherapy is rarely reported. Here, we describe a 71-year-old woman with a progressed unresectable extrahepatic cholangiocarcinoma and biliary obstruction. She had no prior history of muscle weakness and neuromuscular disease with a normal body mass index. She was treated with sintilimab as a rescue regimen of immunotherapy. After the first cycle of treatment, she experienced a grade 4 myopathy including simultaneous myositis, myalgia, and myocarditis due to multiple injuries in her cardiac, skeletal, and ocular muscles. She had elevated levels of creatine kinase (CK), cardiac troponin I, and myoglobin (MYO), but MG and myositis-specific and myositis-related antibodies were negative. Immunotherapy was discontinued and pulse high-dose methylprednisolone with a slow tapering and intravenous immunoglobulin (IVIG) was initiated. Two weeks later, the patient’s clinical presentation improved significantly. A subsequent cardiac magnetic resonance (MR) examination revealed an old myocardial injury that may be a result of immune-related cardiac toxicity. In the third month following the PD-1 inhibitor therapy, she restarted systemic chemotherapy in combination with an anti-angiogenic agent but without immunotherapy. Half a year later, she complained of repeated abdominal distension and radiographic examinations and endoscopy showed a clinically confirmed diagnosis of sliding hiatal hernia of the esophagus and gastroesophageal reflux disease. Due to mild symptoms associated with gastroesophageal reflux, she was suggested close monitoring with acid secretion blockade rather than immediate surgical intervention. The severity for patients with myositis and myocarditis accompanied without MG is similar to those with MG. Considering the use of PD-1 inhibitors is increasing in cancer patients, physicians should therefore pay more attention to immunotherapy-induced myocarditis with myositis/MG overlap syndrome. Since we hypothesize diaphragmatic hiatal hernia as a potential consequence of immunotherapy-induced myositis, reports on hiatal hernias subsequent to immunotherapy-induced myositis are needed.
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Chen R, Zhou M, Zhu F. Immune Checkpoint Inhibitors Related to Cardiotoxicity. J Cardiovasc Dev Dis 2022; 9:jcdd9110378. [PMID: 36354777 PMCID: PMC9697232 DOI: 10.3390/jcdd9110378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have now emerged as a mainstay of treatment for various cancers. Along with development of ICIs, immune-related adverse effects (irAEs) have aroused wide attention. The cardiac irAE, one of the rare but potentially fatal effects, have been reported recently. However, the clinical comprehension of cardiac irAEs remains limited and guidelines are inadequate for cardio-oncologists to tackle the problem. In this review, we have summarized current classifications of, manifestations of, potential mechanisms of, and treatment for ICI-related myocardial injury in order to provide some clues for the understanding of cardiac irAEs in clinical work.
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Affiliation(s)
- Ru Chen
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Clinic Center of Human Gene Research, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Min Zhou
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Key Laboratory of Respiratory Diseases, National Ministry of Health of the People’s Republic of China and National Clinical Research Center for Respiratory Disease, Wuhan 430022, China
- Correspondence: (M.Z.); (F.Z.)
| | - Feng Zhu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Clinic Center of Human Gene Research, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: (M.Z.); (F.Z.)
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 684] [Impact Index Per Article: 342.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Immune Checkpoint Inhibitor-Associated Myositis: A Distinct Form of Inflammatory Myopathy. J Clin Rheumatol 2022; 28:367-373. [PMID: 35696731 DOI: 10.1097/rhu.0000000000001874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Research on the relationship between inflammatory myopathy and malignancy has grown considerably within the last century. Now, the burgeoning field of inflammatory myopathy has yet another player in the mix: immune checkpoint inhibitor-associated myositis (ICI myositis). Immune checkpoint inhibitor-associated myositis is indicated by clinical diagnosis of inflammatory myopathy after initiation of immune checkpoint inhibitor for cancer management. Current literature reflects low prevalence but high mortality associated with ICI myositis, especially when involving myasthenia gravis and myocarditis. Immune checkpoint inhibitor-associated myositis tends to have muscle pain along with weakness, infrequent presentation with dermatitis, or interstitial lung disease and is typically seronegative with scattered, endomysial inflammatory infiltrates on biopsy. The differential diagnosis of ICI myositis includes myasthenia gravis and other neurological immune-related adverse events. Therapeutic approach involves high doses of corticosteroids with a choice of steroid-sparing immunomodulating agent(s) that is primarily driven by expert opinion due to lack of robust research to support one agent over another. There is wide variation in the inclusion criteria for ICI myositis used in previous studies. We review previously used inclusion criteria and suggest an expertise-based classification criterion to provide a standardized definition and allow comparability between studies. There is a critical need for prospective translational and clinical studies that elucidate the pathophysiology of ICI myositis in order to improve evaluation and management of these patients.
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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应 沂, 唐 琦, 杨 恺, 米 悦, 范 宇, 虞 巍, 宋 毅, 何 志, 周 利, 李 学. [Clinical features of immune checkpoint inhibitor-related myositis in patients with urological cancer]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54:644-651. [PMID: 35950386 PMCID: PMC9385516 DOI: 10.19723/j.issn.1671-167x.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICI) have significantly improved the treatment efficacy of a variety of malignant tumors. However, patients may experience a series of special side effects during treatments with ICI. Immune-related myositis after ICI treatment is characterized by autoimmune rheumatic and musculoskeletal damage, which is relatively rare. To analyze the clinical characteristics and outcomes of ICI-associated myositis in urological tumors, we summarized the clinical manifestations, electrophysiological and pathological characteristics, treatments and outcomes in 8 patients. METHODS The clinical data of the 8 patients with immune-related myositis after ICI treatment for urological tumors treated in the Department of Urology, Peking University First Hospital from March 2018 to March 2022 were retrospectively analyzed for demographic characteristics, drug regimen, clinical symptoms, laboratory indices, electromyography examination, pathological manifestations and outcomes. RESULTS The eight patients included 2 females and 6 males with a median age of 68 years, all treated with ICI for urological neoplasms, including 2 upper tract urothelial carcinoma (UTUC), 3 renal cell carcinoma (RCC), and 3 bladder cancer (BCa). The median time between the first ICI treatment and the detection of immune-related myositis was 39.5 days, and the median duration of treatment was 2 sessions. The main symptoms were muscle pain and weakness, 5 cases with ptosis, 3 cases with secondary rhabdomyolysis, 5 cases with myocarditis, 1 case with myasthenia gravis, and 1 case with enterocolitis. Among them, patients with immune-related myocarditis had a shorter interval from the first anti-programmed cell death protein-1 (PD-1) therapy to the onset of immune-related myositis (P=0.042) compared with patients without myocarditis. The 8 patients had significant elevation of transaminases and muscle enzyme profile indexes, and 5 patients showed positive auto-antibodies. 3 patients had perfected muscle biopsies and showed typical skeletal muscle inflammatory myopathy-like pathological changes with CD3+, CD4+, CD8+, CD20+ lymphocytes and CD68+ macrophage infiltration. After the diagnosis of immune-related myositis, all the 8 patients immediately discontinued ICI therapy and improved after intravenous administration of methylprednisolone alone or in combination with gamma-globulin. CONCLUSION Immune-related myositis after ICI treatment is an immune-related adverse reactions (irAEs) with unique clinical and pathological features, commonly combined with cardiovascular adverse reactions. Immediate discontinuation of ICI and initiation of glucocorticoid therapy may improve the patient's condition in a timely manner.
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Affiliation(s)
- 沂岑 应
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 琦 唐
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 恺惟 杨
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 悦 米
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 宇 范
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 巍 虞
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 毅 宋
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 志嵩 何
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 利群 周
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
| | - 学松 李
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心,北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
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Yan YD, Zhao Y, Zhang C, Fu J, Su YJ, Cui XL, Ma EL, Liu BL, Gu ZC, Lin HW. Toxicity spectrum of immunotherapy in advanced lung cancer: A safety analysis from clinical trials and a pharmacovigilance system. EClinicalMedicine 2022; 50:101535. [PMID: 35812997 PMCID: PMC9256649 DOI: 10.1016/j.eclinm.2022.101535] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND With the increased use of immune checkpoint inhibitors (ICIs) in advanced lung cancer, adverse events (AEs), particularly immune-related AEs (irAEs), have garnered considerable interest. We conducted a comprehensive assessment of the toxicity profile in advanced lung cancer using multi-source medical data. METHODS First, we systematically searched the PubMed, Embase, and Cochrane Library databases (from inception to 10 August 2021) for relevant randomised controlled trials (RCTs) involving ICI-based treatments for advanced lung cancer. The primary outcomes were treatment-related AEs and irAEs, including events that were assigned grade 1-5 and 3-5. The secondary outcomes were grade 5 AEs and irAEs (grade 1-5 and grade 3-5) in specific organs. Network comparisons were conducted for 11 treatments, including chemotherapy (CT), ICI monotherapy (three regimens: programmed death-1 receptor [PD-1] inhibitors, programmed death ligand-1 [PD-L1] inhibitors, and cytotoxic T lymphocyte-associated antigen [CTLA-4] inhibitors), dual-ICI combination therapy (two regimens), and treatment using one or two ICI drugs administered in combination with CT (five regimens). We also conducted a disproportionality analysis by extracting reports of various irAEs associated with ICIs from the FDA Adverse Event Reporting System (FAERS) database. The reporting odds ratios and fatality proportions of different irAEs were calculated and compared. PROSPERO: CRD42021268650. FINDINGS Overall, 41 RCTs involving 23,121 patients with advanced lung cancer were included. Treatments containing chemotherapy increased the risk of treatment-related AEs compared to ICI-based regimens without chemotherapy. Concerning irAEs, PD-L1 + CTLA-4 + CT was associated with the highest risk of grade 1-5 irAEs, followed by two regimens of dual ICI combination, three regimens of ICI monotherapy, and three regimens of one ICI combined with CT. For 3-5 irAEs, CTLA-4 accounted for most AEs. Detailed comparisons of ICI-based treatment options provided irAE profiles based on specific organs/systems and AE severity. Insights from the FAERS database revealed that signals corresponding to pneumonitis, colitis, thyroiditis, and hypophysitis were observed across all ICI regimens. Further analyses of the outcomes indicated that myocarditis (163 of 367, 44.4%), pneumonitis (1610 of 4497, 35.8%), and hepatitis (290 of 931, 31.1%) had high fatality rates. INTERPRETATION Included RCTs showed heterogeneity in a few clinical factors, and reports derived from the FAERS database might have involved inaccurate data. Our results can be used as a basis for improving clinical treatment strategies and designing preventive methods for ICI treatment in advanced lung cancer. FUNDING This study was supported by the Research Project of Drug Clinical Comprehensive Evaluation and Drug Treatment Pathway (SHYXH-ZP-2021-001, SHYXH-ZP-2021-006), Clinical Research Innovation and Cultivation Fund of Ren Ji Hospital (RJPY-LX-008), Ren Ji Boost Project of National Natural Science Foundation of China (RJTJ-JX-001), and Shanghai "Rising Stars of Medical Talent" Youth Development Program - Youth Medical Talents - Clinical Pharmacist Program (SHWJRS (2019) 072).
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Affiliation(s)
- Yi-Dan Yan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
- Drug Clinical Comprehensive Evaluation Group, Shanghai Pharmaceutical Association, Shanghai 200040, China
| | - Ying Zhao
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Chi Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
- Drug Clinical Comprehensive Evaluation Group, Shanghai Pharmaceutical Association, Shanghai 200040, China
| | - Jie Fu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Ying-Jie Su
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
- Drug Clinical Comprehensive Evaluation Group, Shanghai Pharmaceutical Association, Shanghai 200040, China
| | - Xiang-Li Cui
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Er-Li Ma
- Drug Clinical Comprehensive Evaluation Group, Shanghai Pharmaceutical Association, Shanghai 200040, China
| | - Bing-Long Liu
- Drug Clinical Comprehensive Evaluation Group, Shanghai Pharmaceutical Association, Shanghai 200040, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
- Drug Clinical Comprehensive Evaluation Group, Shanghai Pharmaceutical Association, Shanghai 200040, China
- Corresponding author at: Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China.
| | - Hou-Wen Lin
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
- Corresponding author.
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Plaçais L, Dalle S, Dereure O, Trabelsi S, Dalac S, Legoupil D, Montaudié H, Arnault JP, De Quatrebarbes J, Saiag P, Brunet-Possenti F, Lesimple T, Maubec E, Aubin F, Granel-Brocard F, Grob JJ, Stoebner PE, Allayous C, Oriano B, Dutriaux C, Mortier L, Lebbe C. Risk of irAEs in patients with autoimmune diseases treated by immune checkpoint inhibitors for stage III or IV melanoma: results from a matched case-control study. Ann Rheum Dis 2022; 81:1445-1452. [PMID: 35788496 DOI: 10.1136/ard-2022-222186] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/15/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To quantify the risk of immune-related adverse events (irAEs) in patients with pre-existing autoimmune disease (pAID) treated by immune checkpoint inhibitors (ICIs) for stage III or IV melanoma. METHODS Case-control study performed on a French multicentric prospective cohort of patients with melanoma, matched for irAE risk factors and oncological staging. Risk of irAE was assessed by logistic regression. RESULTS 110 patients with pAID were included and matched with 330 controls, from March 2013 to October 2020. Over a median follow-up period of 7.2 months for cases and 6.9 months for controls, the ORs of developing all-grade and grade ≥3 irAEs among cases compared with controls were 1.91 (95% CI (1.56 to 2.27)) and 1.44 (95% CI (1.08 to 1.82)), respectively. Patients with pAID had an increased risk of multiple irAEs (OR 1.46, 95% CI (1.15 to 2.67)) and a shorter time to irAE onset. In contrast, there were no difference in irAE-related mortality nor in the rate of treatment discontinuation, and a landmark analysis revealed a better survival at 24 months among cases (p=0.02). Thirty per cent of cases experienced a pAID flare during follow-up, and baseline immunosuppression did not prevent irAE occurrence. Last, we report associations between the pAID clinical subsets and organ-specific irAEs. CONCLUSION In our study, patients with pAID were at greater risk of all-grade, severe and multiple irAEs, yet had a better 24-month survival than controls. Thus, patients with pAID should be eligible for ICI therapy but benefit from a close monitoring for irAE occurrence, especially during the first months of therapy.
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Affiliation(s)
- Léo Plaçais
- Internal Medicine and Clinical Immunology, Hopital Bicêtre, Le Kremlin-Bicêtre, Île-de-France, France
| | - Stéphane Dalle
- Dermatology, Centre Hospitalier Universitaire de Lyon, Lyon, Rhône-Alpes, France
| | - Olivier Dereure
- Dermatology, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Sabiha Trabelsi
- Dermatology, CHU Grenoble Alpes, Grenoble, Auvergne-Rhone-Alpes, France
| | - Sophie Dalac
- Dermatology, CHU Dijon, Dijon, Bourgogne, France
| | | | | | - Jean-Philippe Arnault
- Dermatology, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, Hauts-de-France, France
| | | | - Philippe Saiag
- Dermatology, Hôpital Ambroise Paré, Neuilly-sur-Seine, Île-de-France, France
| | | | | | - Eve Maubec
- Dermatology, Hopital Avicenne, Bobigny, France
| | | | | | - Jean-Jacques Grob
- Dermatology, Hôpital de la Timone, Marseille, Provence-Alpes-Côte d'Azu, France
| | | | - Clara Allayous
- Dermatology, CHU Saint-Louis, Paris, Île-de-France, France
| | - Bastien Oriano
- Dermatology, CHU Saint-Louis, Paris, Île-de-France, France
| | - Caroline Dutriaux
- Dermatology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, Aquitaine, France
| | | | - Céleste Lebbe
- Dermatology, Hopital Saint-Louis, Paris, Île-de-France, France
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Hu ZI, Link VM, Lima-Junior DS, Delaleu J, Bouladoux N, Han SJ, Collins N, Belkaid Y. Immune checkpoint inhibitors unleash pathogenic immune responses against the microbiota. Proc Natl Acad Sci U S A 2022; 119:e2200348119. [PMID: 35727974 PMCID: PMC9245641 DOI: 10.1073/pnas.2200348119] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/05/2022] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are essential components of the cancer therapeutic armamentarium. While ICIs have demonstrated remarkable clinical responses, they can be accompanied by immune-related adverse events (irAEs). These inflammatory side effects are of unclear etiology and impact virtually all organ systems, with the most common being sites colonized by the microbiota such as the skin and gastrointestinal tract. Here, we establish a mouse model of commensal bacteria-driven skin irAEs and demonstrate that immune checkpoint inhibition unleashes commensal-specific inflammatory T cell responses. These aberrant responses were dependent on production of IL-17 by commensal-specific T cells and induced pathology that recapitulated the cutaneous inflammation seen in patients treated with ICIs. Importantly, aberrant T cell responses unleashed by ICIs were sufficient to perpetuate inflammatory memory responses to the microbiota months following the cessation of treatment. Altogether, we have established a mouse model of skin irAEs and reveal that ICIs unleash aberrant immune responses against skin commensals, with long-lasting inflammatory consequences.
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Affiliation(s)
- Zishuo Ian Hu
- Metaorganism Immunity Section, Laboratory of Host Immunity and Microbiome, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
- National Cancer Institute, Medical Oncology Fellowship Program, NIH, Bethesda, MD 20892
| | - Verena M. Link
- Metaorganism Immunity Section, Laboratory of Host Immunity and Microbiome, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Djalma S. Lima-Junior
- Metaorganism Immunity Section, Laboratory of Host Immunity and Microbiome, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Jérémie Delaleu
- Metaorganism Immunity Section, Laboratory of Host Immunity and Microbiome, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Nicolas Bouladoux
- Metaorganism Immunity Section, Laboratory of Host Immunity and Microbiome, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Seong-Ji Han
- Metaorganism Immunity Section, Laboratory of Host Immunity and Microbiome, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Nicholas Collins
- Metaorganism Immunity Section, Laboratory of Host Immunity and Microbiome, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Yasmine Belkaid
- Metaorganism Immunity Section, Laboratory of Host Immunity and Microbiome, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
- Microbiome Program, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
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Strang P. Palliative oncology and palliative care. Mol Oncol 2022; 16:3399-3409. [PMID: 35762045 PMCID: PMC9533690 DOI: 10.1002/1878-0261.13278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/23/2022] [Accepted: 06/25/2022] [Indexed: 12/02/2022] Open
Abstract
New therapeutic approaches can produce promising results even in severely ill cancer patients. But they also pose new challenges with respect to prognostication, as patients who were once not eligible for treatment, due to age or comorbidities, now are. Palliative oncology constitutes a major part of oncological care, with life prolongation and quality of life as its main goals. Palliative care specialists are experts in symptom control and psychosocial and existential support, and the integration of their expertise early on in patient care can prolong survival. In this article, I discuss the need to integrate specialist palliative care into early cancer treatment plans to achieve quality of life for patients. I also discuss the ways in which palliative care specialists balance the benefits of novel treatments against their adverse effects for patients, particularly for the elderly, the frail and those in advance stages of disease. I highlight the need to ensure equal access to palliative care to improve cancer patients' quality of life but also why futile, burdensome treatments should be avoided especially in the frail, elderly patients. Further, I discuss benefits and problems related to nutritional support in patients with cachexia and exemplify why translational research is needed to link basic research with clinical oncology and effective symptom control.
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Affiliation(s)
- Peter Strang
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm's Sjukhem Foundation, Stockholm, and R & D Department, Sweden
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44
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Greisen SR, Aspari M, Deleuran B. Co-Inhibitory Molecules – Their Role in Health and Autoimmunity; Highlighted by Immune Related Adverse Events. Front Immunol 2022; 13:883733. [PMID: 35784333 PMCID: PMC9243421 DOI: 10.3389/fimmu.2022.883733] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/10/2022] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint receptors are key players in regulating the immune response. They are responsible for both generating an immune response sufficient to kill invading pathogens, balancing the same response, and protecting against tissue destruction or the development of autoimmune events. The central role of the co-inhibitory receptors also referred to as inhibitory immune checkpoints, including PD-1 and CTLA-4 has become especially evident with the cancer treatments targeting these receptors. Blocking these pathways enhances the immune activity, resulting in both an increased chance of cancer clearance, at the same time induction of immune-related adverse events (irAE). Some of these irAE progress into actual autoimmune diseases with autoantibodies and symptoms, undistinguished from the naturally occurring diseases. This review will take advantage of the lessons learned from immune checkpoint blockade and relate this knowledge to our understanding of the same pathways in naturally occurring autoimmune diseases, mainly focusing on rheumatic diseases.
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Affiliation(s)
- Stinne R. Greisen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- *Correspondence: Stinne R. Greisen,
| | - Maithri Aspari
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Bent Deleuran
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
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45
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Nakagomi Y, Tajiri K, Shimada S, Li S, Inoue K, Murakata Y, Murata M, Sakai S, Sato K, Ieda M. Immune Checkpoint Inhibitor-Related Myositis Overlapping With Myocarditis: An Institutional Case Series and a Systematic Review of Literature. Front Pharmacol 2022; 13:884776. [PMID: 35645839 PMCID: PMC9135130 DOI: 10.3389/fphar.2022.884776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/27/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Immune checkpoint inhibitor (ICI)-related myositis with myocarditis is a rare but potentially fatal immune-related adverse event. However, its clinical features, response to immunosuppressive treatment, and prognosis remain poorly understood. Here, we describe the clinical course of patients with ICI-related myositis overlapping with myocarditis treated at our institution and a systematic review focusing on the response to immunosuppressive therapy.Methods: We identified patients who developed ICI-induced myositis with myocarditis and were treated at our hospital using a retrospective chart review of electronic medical records. For the systematic review, studies reporting ICI-induced myositis with myocarditis were identified using the Cochrane Library and PubMed databases.Results: Of the 625 patients treated with ICIs, four developed myositis with concurrent myocarditis. All the patients received immunosuppressive therapy. We assessed the activity of myocarditis and myositis based on temporal changes in troponin and creatine kinase (CK) levels. In all patients, peak troponin values appeared later than the peak CK values (median, 17 days). The median time from the start of ICI therapy to the peak of troponin and CK levels was 42.5 and 28 days, respectively. In all patients, CK levels decreased rapidly and steadily after the initiation of immunosuppressants. However, troponin levels were unstable and increased. In all patients, CK levels normalized within one month (range, 12–27 days), but troponin levels took several months to normalize (range, 84–161 days). Fourteen cases of ICI-related myositis with myocarditis were included in the systematic review. Of the 14 cases, 12 (86%) had their CK level decreased after the initial steroid treatment, but the troponin level increased and was higher than that before the start of treatment. In addition, the peak troponin values appeared later than the peak CK values (a median of 6.5 days). Eight (89%) of 9 long-term follow-up patients had troponin levels above the normal range even after CK normalization.Conclusion: In most cases of ICI-related myositis with myocarditis, troponin levels increased after the initial steroid treatment despite decreased CK levels, and exceeded pre-steroid levels. In addition, troponin remained elevated for several months after CK normalized.
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Affiliation(s)
- Yuki Nakagomi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kazuko Tajiri
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Cardiology, National Cancer Center Hospital East, Kashiwa, Japan
- *Correspondence: Kazuko Tajiri,
| | - Saori Shimada
- Department of Pharmacy, University of Tsukuba Hospital, Tsukuba, Japan
| | - Siqi Li
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Keiko Inoue
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshiko Murakata
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Momoko Murata
- Clinical Laboratory, University of Tsukuba Hospital, Tsukuba, Japan
| | - Shunsuke Sakai
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kimi Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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46
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Poto R, Troiani T, Criscuolo G, Marone G, Ciardiello F, Tocchetti CG, Varricchi G. Holistic Approach to Immune Checkpoint Inhibitor-Related Adverse Events. Front Immunol 2022; 13:804597. [PMID: 35432346 PMCID: PMC9005797 DOI: 10.3389/fimmu.2022.804597] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) block inhibitory molecules, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), or its ligand, programmed cell death protein ligand 1 (PD-L1) and enhance antitumor T-cell activity. ICIs provide clinical benefits in a percentage of patients with advanced cancers, but they are usually associated with a remarkable spectrum of immune-related adverse events (irAEs) (e.g., rash, colitis, hepatitis, pneumonitis, endocrine, cardiac and musculoskeletal dysfunctions). Particularly patients on combination therapy (e.g., anti-CTLA-4 plus anti-PD-1/PD-L1) experience some form of irAEs. Different mechanisms have been postulated to explain these adverse events. Host factors such as genotype, gut microbiome and pre-existing autoimmune disorders may affect the risk of adverse events. Fatal ICI-related irAEs are due to myocarditis, colitis or pneumonitis. irAEs usually occur within the first months after ICI initiation but can develop as early as after the first dose to years after ICI initiation. Most irAEs resolve pharmacologically, but some appear to be persistent. Glucocorticoids represent the mainstay of management of irAEs, but other immunosuppressive drugs can be used to mitigate refractory irAEs. In the absence of specific trials, several guidelines, based on data from retrospective studies and expert consensus, have been published to guide the management of ICI-related irAEs.
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Affiliation(s)
- Remo Poto
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Teresa Troiani
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gjada Criscuolo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | | | - Fortunato Ciardiello
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,World Allergy Organization (WAO) Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
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47
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Johnson DB, Nebhan CA, Moslehi JJ, Balko JM. Immune-checkpoint inhibitors: long-term implications of toxicity. Nat Rev Clin Oncol 2022; 19:254-267. [PMID: 35082367 PMCID: PMC8790946 DOI: 10.1038/s41571-022-00600-w] [Citation(s) in RCA: 382] [Impact Index Per Article: 191.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/15/2022]
Abstract
The development of immune-checkpoint inhibitors (ICIs) has heralded a new era in cancer treatment, enabling the possibility of long-term survival in patients with metastatic disease, and providing new therapeutic indications in earlier-stage settings. As such, characterizing the long-term implications of receiving ICIs has grown in importance. An abundance of evidence exists describing the acute clinical toxicities of these agents, although chronic effects have not been as well catalogued. Nonetheless, emerging evidence indicates that persistent toxicities might be more common than initially suggested. While generally low-grade, these chronic sequelae can affect the endocrine, rheumatological, pulmonary, neurological and other organ systems. Fatal toxicities also comprise a diverse set of clinical manifestations and can occur in 0.4-1.2% of patients. This risk is a particularly relevant consideration in light of the possibility of long-term survival. Finally, the effects of immune-checkpoint blockade on a diverse range of immune processes, including atherosclerosis, heart failure, neuroinflammation, obesity and hypertension, have not been characterized but remain an important area of research with potential relevance to cancer survivors. In this Review, we describe the current evidence for chronic immune toxicities and the long-term implications of these effects for patients receiving ICIs.
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Affiliation(s)
- Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA.
| | - Caroline A Nebhan
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Javid J Moslehi
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Justin M Balko
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
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48
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Siu DHW, O'Neill RS, Harris CA, Wang J, Ardolino L, Downton T, Tong M, Hong JH, Chin V, Clingan PR, Aghmesheh M, Soudy H. Immune checkpoint inhibitor-induced myocarditis, myositis, myasthenia gravis and transaminitis: a case series and review. Immunotherapy 2022; 14:511-520. [PMID: 35321560 DOI: 10.2217/imt-2021-0225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors have been incorporated into the treatment of various malignancies. An increasing body of literature is reporting rare but potentially fatal adverse events associated with these agents. In this case series, the authors report the clinical features and outcomes of seven patients who received immune checkpoint inhibitors for different solid organ malignancies and developed a tetrad of immune-related myocarditis, myositis, myasthenia gravis and transaminitis. Herein the authors review the literature and describe the current diagnostic and management approach for this overlapping syndrome. The authors' series highlights the importance of a high index of clinical suspicion, prompt comprehensive investigations, early multidisciplinary team involvement and initiation of immunosuppressive therapy when immune-related adverse events are suspected.
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Affiliation(s)
- Derrick Ho Wai Siu
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, 2050, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia
| | - Robert Sean O'Neill
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Carole A Harris
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Justine Wang
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Neurology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia
| | - Luke Ardolino
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, The Kinghorn Centre, St Vincent's Hospital, Darlinghurst, New South Wales, 2010, Australia
| | - Teesha Downton
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia
| | - Matthew Tong
- Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Jun Hee Hong
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia
| | - Venessa Chin
- Department of Medical Oncology, The Kinghorn Centre, St Vincent's Hospital, Darlinghurst, New South Wales, 2010, Australia.,Single Cell and Computational Genomics Lab, The Garvan Institute of Medical Research, Darlinghurst, New South Wales, 2010, Australia
| | - Philip R Clingan
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia.,University of Wollongong, New South Wales, Australia
| | - Morteza Aghmesheh
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia.,University of Wollongong, New South Wales, Australia
| | - Hussein Soudy
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
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Ammirati E, Bizzi E, Veronese G, Groh M, Van de Heyning CM, Lehtonen J, Pineton de Chambrun M, Cereda A, Picchi C, Trotta L, Moslehi JJ, Brucato A. Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis. Front Med (Lausanne) 2022; 9:838564. [PMID: 35350578 PMCID: PMC8958011 DOI: 10.3389/fmed.2022.838564] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
The field of inflammatory disease of the heart or "cardio-immunology" is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.
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Affiliation(s)
- Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy
| | - Emanuele Bizzi
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Giacomo Veronese
- Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Matthieu Groh
- National Reference Center for Hypereosinophilic Syndromes, CEREO, Suresnes, France
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Caroline M. Van de Heyning
- Department of Cardiology, Antwerp University Hospital, and GENCOR Research Group, Antwerp University, Antwerp, Belgium
| | - Jukka Lehtonen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
- Sorbonne Université, APHP, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence National Lupus et SAPL et Autres Maladies Auto-immunes et Systémiques Rares, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, ICAN, Paris, France
| | - Alberto Cereda
- Cardiovascular Department, Association Socio Sanitary Territorial Santi Paolo e Carlo, Milano, Italy
| | - Chiara Picchi
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Lucia Trotta
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Javid J. Moslehi
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco, ” Fatebenefratelli Hospital, University of Milano, Milano, Italy
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50
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Cunningham-Bussel A, Wang J, Prisco LC, Martin LW, Vanni KM, Zaccardelli A, Nasrallah M, Gedmintas L, MacFarlane LA, Shadick NA, Awad MM, Rahma O, LeBoeuf NR, Gravallese EM, Sparks JA. Predictors of Rheumatic Immune-Related Adverse Events and De Novo Inflammatory Arthritis After Immune Checkpoint Inhibitor Treatment for Cancer. Arthritis Rheumatol 2022; 74:527-540. [PMID: 34397169 PMCID: PMC8847547 DOI: 10.1002/art.41949] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/29/2021] [Accepted: 08/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To identify predictors of rheumatic immune-related adverse events (irAEs) following immune checkpoint inhibitor (ICI) treatment for cancer. METHODS We performed a case-control study to predict the occurrence of rheumatic irAEs in cancer patients who initiated ICI treatment at Mass General Brigham and the Dana-Farber Cancer Institute between 2011 and 2020. We screened for the presence of rheumatic irAEs by reviewing the medical records of patients evaluated by rheumatologists or those prescribed nonglucocorticoid immunomodulatory drugs after the time of ICI initiation (baseline). Review of medical records confirmed the presence of rheumatic irAEs and the indications necessitating immunomodulatory drug treatment. Controls were defined as patients who did not experience rheumatic irAEs, did not have preexisting rheumatic disease, did not have a clinical evaluation by a rheumatologist after ICI treatment, did not receive an immunomodulatory drug after ICI, did not receive systemic glucocorticoids after ICI, and survived at least 6 months after the initial ICI treatment. We used logistic regression to estimate the odds ratios (ORs) (with 95% confidence intervals [95% CIs]) for the risk of a rheumatic irAE in the presence of various baseline predictors. RESULTS A total of 8,028 ICI recipients were identified (mean age 65.5 years, 43.1% female, 31.8% with lung cancer). After ICI initiation, 404 patients (5.0%) were evaluated by rheumatologists, and 475 patients (5.9%) received an immunomodulatory drug to treat any irAEs. There were 226 confirmed rheumatic irAE cases (2.8%) and 118 de novo inflammatory arthritis cases (1.5%). Rheumatic diseases (either preexisting rheumatic diseases or rheumatic irAEs) were a common indication for immunomodulatory drug use (27.9%). Baseline predictors of rheumatic irAEs included melanoma (multivariable OR 4.06 [95% CI 2.54-6.51]) and genitourinary (GU) cancer (OR 2.22 [95% CI 1.39-3.54]), both relative to patients with lung cancer; combination ICI treatment (OR 2.35 [95% CI 1.48-3.74]), relative to patients receiving programmed death 1 inhibitor monotherapy; autoimmune disease (OR 2.04 [95% CI 1.45-2.85]) and recent glucocorticoid use (OR 2.13 [95% CI 1.51-2.98]), relative to patients not receiving a glucocorticoid, compared to the 2,312 controls without rheumatic irAEs. Predictors of de novo inflammatory arthritis were similar to those of rheumatic irAEs. CONCLUSION We identified novel predictors of rheumatic irAE development in cancer patients, including baseline presence of melanoma, baseline presence of GU tract cancer, preexisting autoimmune disease, receiving or having received combination ICI treatment, and receiving or having received glucocorticoids. The proportion of cancer patients experiencing rheumatic irAEs may be even higher than was reported in the present study, since we used stringent criteria to identify cases of rheumatic irAEs. Our findings could be used to identify cancer patients at risk of developing rheumatic irAEs and de novo inflammatory arthritis and may help further elucidate the pathogenesis of rheumatic irAEs in patients with cancer who are receiving ICI treatment.
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Affiliation(s)
- Amy Cunningham-Bussel
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Jiaqi Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lauren C. Prisco
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lily W. Martin
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kathleen M.M. Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alessandra Zaccardelli
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mazen Nasrallah
- Harvard Medical School, Boston, MA, USA,Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Lydia Gedmintas
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Lindsey A. MacFarlane
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Nancy A. Shadick
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Mark M. Awad
- Harvard Medical School, Boston, MA, USA,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Osama Rahma
- Harvard Medical School, Boston, MA, USA,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nicole R. LeBoeuf
- Harvard Medical School, Boston, MA, USA,Dana-Farber Cancer Institute, Boston, MA, USA,Department of Dermatology, Brigham and Women’s Hospital
| | - Ellen M. Gravallese
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Jeffrey A. Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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