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Shalata W, Steckbeck R, Abu Salman A, Abu Saleh O, Abu Jama A, Attal ZG, Shalata S, Alnsasra H, Yakobson A. Perimyocarditis Associated with Immune Checkpoint Inhibitors: A Case Report and Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:224. [PMID: 38399513 PMCID: PMC10890382 DOI: 10.3390/medicina60020224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Patient prognoses have been significantly enhanced by immune checkpoint inhibitors (ICIs), altering the standard of care in cancer treatment. These novel antibodies have become a mainstay of care for metastatic non-small-cell lung cancer (mNSCLC) patients. Several types of adverse events related to ICIs have been identified and documented as a result of the launch of these innovative medicines. We present here a 74-year-old female patient with a stage IV lung adenocarcinoma, treated with nivolumab plus ipilimumab, who developed perimyocarditis two weeks after receiving the third cycle of immune checkpoint inhibitor therapy. The patient was diagnosed using troponin levels, computed tomography (CT) angiography, and echocardiography. After hospitalization, her cardiac condition was successfully resolved with corticosteroids, colchicine, and symptomatic treatment. To the best of our knowledge, this is one of the rarest cases to be reported of perimyocarditis as a toxicity of immunotherapy in a patient treated for adenocarcinoma of the lung.
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Affiliation(s)
- Walid Shalata
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Rachel Steckbeck
- Medical School for International Health and Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Amjad Abu Salman
- Cardiology Department, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Omar Abu Saleh
- Department of Dermatology and Venereology, Emek Medical Centre, Afula 18341, Israel
| | - Ashraf Abu Jama
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Zoé Gabrielle Attal
- Medical School for International Health and Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Sondos Shalata
- Nutrition Unit, Galilee Medical Center, Nahariya 22000, Israel
| | - Hilmi Alnsasra
- Cardiology Department, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Alexander Yakobson
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
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Rong Y, Bentley JP, Bhattacharya K, Yang Y, Chang Y, Earl S, Ramachandran S. Incidence and risk factors of immune-related adverse events induced by immune checkpoint inhibitors among older adults with non-small cell lung cancer. Cancer Med 2024; 13:e6879. [PMID: 38164655 PMCID: PMC10807682 DOI: 10.1002/cam4.6879] [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: 07/26/2023] [Revised: 10/31/2023] [Accepted: 12/16/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) treatment has been linked to a variety of immune-related adverse events (irAEs), which can affect any organ system. The incidence and risk factors of irAEs have not been adequately evaluated among older adults with NSCLC. METHODS A cohort study was conducted using 1999-2019 SEER-Medicare data among beneficiaries aged ≥65 years with a diagnosis of NSCLC who received nivolumab, pembrolizumab, or atezolizumab. Incident irAEs were identified post-ICI initiation. Demographic, cancer-related characteristics, and clinical history risk factors of irAEs were evaluated with competing events considered. RESULTS A total of 8175 older NSCLC patients were included (with 46.8% experiencing irAEs). Pneumonitis (16.5%), hypothyroidism (10.5%), arrhythmia (11.18%), and acute kidney injury (AKI) (5.8%) were the most common irAEs. The median time to first irAE was 82 days (IQR: 29-182 days). The earliest onset of irAE occurrence was for hematologic irAEs, while the latest were gastrointestinal, dermatologic, and musculoskeletal irAEs. Fine-Gray regression modeling revealed significantly greater hazards of irAE occurrence in patients who received pembrolizumab at index, did not have CNS metastases, had a history of autoimmune disorder, and had chemotherapy in combination with ICI. Race, socioeconomic status, previous radiation therapy, and comorbidity burden were found to be associated with the occurrence of certain type of irAEs. CONCLUSION A significant proportion of older patients with NSCLC develop an irAE after receiving ICI treatment. Factors related to cancer and treatment as well as demographics contribute to the increased risk of irAEs. Close monitoring and prediction of irAE among older patients receiving ICI is warranted.
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Affiliation(s)
- Yiran Rong
- Department of Pharmacy AdministrationUniversity of MississippiUniversityMississippiUSA
| | - John P. Bentley
- Department of Pharmacy AdministrationUniversity of MississippiUniversityMississippiUSA
- Center for Pharmaceutical Marketing and ManagementCenter for Pharmaceutical Marketing and ManagementUniversity of MississippiUniversityMississippiUSA
| | - Kaustuv Bhattacharya
- Department of Pharmacy AdministrationUniversity of MississippiUniversityMississippiUSA
- Center for Pharmaceutical Marketing and ManagementCenter for Pharmaceutical Marketing and ManagementUniversity of MississippiUniversityMississippiUSA
| | - Yi Yang
- Department of Pharmacy AdministrationUniversity of MississippiUniversityMississippiUSA
| | - Yunhee Chang
- Department of Nutrition and Hospitality ManagementUniversity of MississippiUniversityMississippiUSA
| | - Sally Earl
- Department of Pharmacy PracticeUniversity of MississippiUniversityMississippiUSA
| | - Sujith Ramachandran
- Department of Pharmacy AdministrationUniversity of MississippiUniversityMississippiUSA
- Center for Pharmaceutical Marketing and ManagementCenter for Pharmaceutical Marketing and ManagementUniversity of MississippiUniversityMississippiUSA
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3
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Cook S, Samuel V, Meyers DE, Stukalin I, Litt I, Sangha R, Morris DG, Heng DYC, Pabani A, Dean M, Navani V. Immune-Related Adverse Events and Survival Among Patients With Metastatic NSCLC Treated With Immune Checkpoint Inhibitors. JAMA Netw Open 2024; 7:e2352302. [PMID: 38236598 PMCID: PMC10797458 DOI: 10.1001/jamanetworkopen.2023.52302] [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] [Received: 08/17/2023] [Accepted: 11/28/2023] [Indexed: 01/19/2024] Open
Abstract
Importance Immune-related adverse events (irAEs) secondary to immune checkpoint inhibitor (ICI) therapy reportedly improve overall survival (OS) in patients with non-small cell lung cancer (NSCLC). However, studies have been small and the association between irAE severity and OS remains poorly defined. Objective To examine the association between irAEs and their severity with OS in patients with locally advanced or metastatic NSCLC receiving ICIs. Design, Setting, and Participants This retrospective observational cohort study included patients with NSCLC receiving ICIs between March 1, 2014, and November 30, 2021, with follow-up until March 31, 2023. Data analysis was completed April 26, 2023. The Alberta Immunotherapy Database, a provincial, multicenter cohort, was used to capture data from patients receiving ICIs in Alberta, Canada. Participants included 803 patients 18 years or older who received at least 1 cycle of ICI (alone or with chemotherapy), agnostic to treatment line. Exposure Developing an irAE mandating delay or discontinuation of ICI therapy and/or systematic corticosteroids for management of toxic effects (hereinafter referred to as clinically meaningful irAEs). Main Outcomes and Measures The primary outcome was association between irAEs and OS according to Kaplan-Meier analysis. Clinically meaningful irAEs were identified. Patients with poor prognosis (survival <3 months) who may have died prior to irAE development were excluded from OS analysis, mitigating immortal time bias. Adjusted Cox proportional hazards regression analyses ascertained variables associated with OS. Results Among the 803 patients included in the analysis, the median age of patients with irAEs was 69.7 (IQR, 63.1-75.2) years and the median age of those without irAEs was 67.5 (IQR, 60.4-73.3) years, with comparable sex distribution (139 of 295 men [47.1%] and 156 of 295 women [52.9%] with irAEs vs 254 of 505 men [50.3%] and 251 of 505 women [49.7%] without irAEs). Mitigating immortal time bias (n = 611), irAEs were associated with OS (median OS with irAEs, 23.7 [95% CI, 19.3-29.1] months; median OS without irAEs, 9.8 [95% CI, 8.7-11.4] months; P < .001). No OS difference was associated with treatment in hospital vs as outpatients for an irAE (median OS, 20.8 [95% CI, 11.7-30.6] vs 25.6 [95% CI, 20.1-29.8] months; P = .33). Developing irAEs remained associated with OS in the total cohort after Cox proportional hazards regression with known prognostic characteristics (hazard ratio, 0.53 [95% CI, 0.40-0.70]; P < .001). Conclusions and Relevance In this cohort study of 803 patients with locally advanced or metastatic NSCLC receiving ICIs, developing a clinically meaningful irAE was associated with improved OS. This association was not compromised by hospitalization for severe toxic effects. Whether and how ICI therapy resumption after an irAE is associated with OS warrants further study.
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Affiliation(s)
- Sarah Cook
- Department of Medical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Vanessa Samuel
- Department of Medical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Daniel E. Meyers
- Department of Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Igor Stukalin
- Department of Medical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Ishjot Litt
- Department of Medical Oncology, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Aliyah Pabani
- Department of Oncology, Johns Hopkins University, Baltimore, Maryland
| | - Michelle Dean
- Department of Medical Oncology, University of Calgary, Calgary, Alberta, Canada
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Shalata W, Attal ZG, Shhadi R, Abu Salman A, Abu Jama A, Shalata S, Halumi K, Yakobson A. Tolerated Re-Challenge of Immunotherapy in a Patient with ICI Associated Myocarditis: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1946. [PMID: 38003995 PMCID: PMC10673034 DOI: 10.3390/medicina59111946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023]
Abstract
Many different types of cancer can be treated with immunotherapy drugs called immune checkpoint inhibitors (ICIs). These drugs have altered the landscape of cancer treatment options since they function by triggering a stronger immune response to malignancy. As expected, ICIs' modification of immune regulatory controls leads to a wide range of organ/gland-specific immune-related side effects. These adverse effects are uncommonly deadly and typically improve by discontinuing treatment or administering corticosteroid drugs. As a result of a number of factors-including a lack of specificity in the clinical presentation, the possibility of overlap with other cardiovascular and general medical illnesses, difficulties in diagnosis, and a general lack of awareness-the true incidence of ICI-associated myocarditis is likely underestimated. Currently, protocols for the surveillance, diagnosis, or treatment of this condition are unclear. Several questions remain unanswered, such as how to best screen for this rare toxin, what tests should be run on patients who are suspected of having it, how to treat myocarditis once it has developed, and who is at most risk. In this article, we provide a case study of ICI-associated myocarditis and explain its key characteristics and treatment options.
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Affiliation(s)
- Walid Shalata
- The Legacy Heritage Cancer Center & Larry Norton Institute, Soroka Medical Center, Beer Sheva 84105, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
| | - Zoé Gabrielle Attal
- Medical School for International Health, Ben Gurion University of the Negev, Beer Sheva 84105, Israel
| | - Rajeh Shhadi
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
| | - Amjad Abu Salman
- Cardiology Division, Soroka Medical Center, Beer Sheva 84105, Israel
| | - Ashraf Abu Jama
- The Legacy Heritage Cancer Center & Larry Norton Institute, Soroka Medical Center, Beer Sheva 84105, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
| | - Sondos Shalata
- Nutrition Unit, Galilee Medical Center, Nahariya 22000, Israel
| | - Kais Halumi
- The Legacy Heritage Cancer Center & Larry Norton Institute, Soroka Medical Center, Beer Sheva 84105, Israel
| | - Alexander Yakobson
- The Legacy Heritage Cancer Center & Larry Norton Institute, Soroka Medical Center, Beer Sheva 84105, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
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Sabaté Ortega J, Fort Culillas R, Escoda Garcia M, Vásquez-Dongo CA, Sala González N. Case Report: A Presentation of Early-Onset Immune-Mediated Bullous Pemphigoid in a Patient with Urothelial Cancer. Curr Oncol 2023; 30:7802-7809. [PMID: 37754481 PMCID: PMC10529691 DOI: 10.3390/curroncol30090566] [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: 07/25/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023] Open
Abstract
Cutaneous immune-related adverse events (cirAEs) are the most common side effects of immune checkpoint inhibitor (ICI) therapy (30-50% for all grades). The vast majority of them are low or mild and can be treated without ICI interruption. Autoimmune blistering disorders, such as immune-mediated bullous pemphigoid (IBP), are rare (<1%) but potentially serious conditions that must be early detected. The onset generally occurs within the first months of the treatment, and it appears to be more common with antiprogrammed death-1 or antiprogrammed ligand 1 (anti-PD1/PDL1) than with anticytotoxic T-lymphocyte-associated protein 4 (anti-CTLA4). We present a case of a three-day severe IBP onset after receiving the first cycle of atezolizumab. This exceptional early presentation could suggest the presence of some predisposing condition and demonstrates the need to better understand predictive toxicity-related biomarkers in candidate patients for immunotherapy.
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Affiliation(s)
- Josep Sabaté Ortega
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | - Roser Fort Culillas
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | - Marina Escoda Garcia
- Dermatology Department, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | | | - Núria Sala González
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
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Özdemir BC, Espinosa da Silva C, Arangalage D, Monney P, Guler SA, Huynh-Do U, Stirnimann G, Possamai L, Trepp R, Hoepner R, Salmen A, Gerard CL, Hruz P, Christ L, Rothschild SI. Multidisciplinary recommendations for essential baseline functional and laboratory tests to facilitate early diagnosis and management of immune-related adverse events among cancer patients. Cancer Immunol Immunother 2023:10.1007/s00262-023-03436-0. [PMID: 37017694 DOI: 10.1007/s00262-023-03436-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/22/2023] [Indexed: 04/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have fundamentally changed the treatment landscape of various cancers. While ICI treatments result in improved survival, quality of life and are cost-effective, the majority of patients experience at least one immune-related adverse event (irAE). Many of these side effects cause little discomfort or are asymptomatic; however, irAEs can affect any organ and are potentially life-threatening. Consequently, early diagnosis and appropriate treatment of irAEs are critical for optimizing long-term outcomes and quality of life in affected patients. Some irAEs are diagnosed according to typical symptoms, others by abnormal findings from diagnostic tests. While there are various guidelines addressing the management of irAEs, recommendations for the early recognition of irAEs as well as the optimal extent and frequency of laboratory tests are mostly lacking. In clinical practice, blood sampling is usually performed before each ICI administration (i.e., every 2-3 weeks), often for several months, representing a burden for patients as well as health care systems. In this report, we propose essential laboratory and functional tests to improve the early detection and management of irAEs and in cancer patients treated with ICIs. These multidisciplinary expert recommendations regarding essential laboratory and functional tests can be used to identify possible irAEs at an early time point, initiate appropriate interventions to improve patient outcomes, and reduce the burden of blood sampling during ICI treatment.
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Affiliation(s)
- Berna C Özdemir
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Cristina Espinosa da Silva
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, USA
| | - Dimitri Arangalage
- Department of Cardiology, INSERM U1148, Bichat Hospital, University of Paris, Paris, France
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Sabina A Guler
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lucia Possamai
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Roman Trepp
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Camille L Gerard
- Department of Oncology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
- The Francis Crick Institute, London, UK
| | - Petr Hruz
- Department of Gastroenterology, University Hospital Basel, Basel, Switzerland
| | - Lisa Christ
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sacha I Rothschild
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department Internal Medicine, Center for Oncology and Hematology, Cantonal Hospital Baden, Baden, Switzerland
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Faucheux A, Olson E, Lantz J, Roberts N, Aggarwal V, Newman I, Ponnatapura J, Lycan T. A Novel Workflow to Create a Checkpoint Inhibitor Pneumonitis Patient Registry. Cureus 2023; 15:e34683. [PMID: 36909081 PMCID: PMC9994379 DOI: 10.7759/cureus.34683] [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: 02/06/2023] [Indexed: 02/09/2023] Open
Abstract
Background Despite being a groundbreaking cancer therapy, immune checkpoint inhibitors (ICI) can lead to potentially life-threatening toxicity with checkpoint inhibitor pneumonitis (CIP). While treatable, it is easy for clinicians to miss the symptoms of CIP, which can lead to a delay in diagnosis and worsening respiratory function. There is no consensus approach to systematically identifying patients at risk of developing CIP. Thus, we sought to create a workflow that could inform patient selection for ICI therapy based on previously reported risk factors for CIP development. Materials and methods We retrospectively identified 250 patients with lung cancer treated with at least one dose of an ICI over 20 months. Data were collected on comorbidities, cancer type and stage, performance status, ICI cycles, biomarkers, prior curative treatment, diagnostic evaluation, antibiotics, steroids, progression, and survival. A single-blinded radiologist characterized radiographic patterns of suspected CIP cases. Results Among 97 patients who received steroids while admitted to the hospital, 12 (6%) had at least one sign or symptom suggestive of CIP. Chronic obstructive pulmonary disease and non-small cell lung cancer subtypes correlated with suspicion of having CIP. CIP was confirmed in five patients (42%) and ruled out (mimics) in seven (58%). Median times until symptoms were 17 months and one month for confirmed and mimic cases, respectively. The median time to confirm or exclude CIP was 5 ± 4 days. Most suspected cases underwent thoracic imaging, blood cultures, and empiric antibiotics. Radiographic patterns in suspected cases included ground glass opacities, organizing pneumonia, acute interstitial pneumonia/acute respiratory distress syndrome, bronchiolitis, radiation recall pneumonitis, hypersensitivity pneumonitis, and post-radiation fibrotic changes. Conclusions CIP mimics are common in clinical practice; therefore, it is reasonable to empirically treat suspected cases with shorter courses of steroids until diagnostic clarity is achieved. This proof-of-concept study demonstrates that this novel workflow can identify the true incidence of CIP, inform treatment decisions, and lead to the development of implementation studies to improve patient care directly.
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Affiliation(s)
- Andrew Faucheux
- Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Eric Olson
- Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Jeffrey Lantz
- Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, USA
| | - Nathan Roberts
- Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, USA
| | - Vanya Aggarwal
- Hematology and Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Indra Newman
- Wake Forest Clinical and Translational Science Institute, Wake Forest University School of Medicine, Winston-Salem, USA
| | | | - Thomas Lycan
- Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, USA
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Williams CD, Allo MA, Gu L, Vashistha V, Press A, Kelley M. Health outcomes and healthcare resource utilization among Veterans with stage IV non-small cell lung cancer treated with second-line chemotherapy versus immunotherapy. PLoS One 2023; 18:e0282020. [PMID: 36809528 PMCID: PMC9942992 DOI: 10.1371/journal.pone.0282020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 02/06/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Until recently, multi-agent chemotherapy (CT) was the standard of care for patients with advanced non-small cell lung cancer (NSCLC). Clinical trials have confirmed benefits in overall survival (OS) and progression-free survival with immunotherapy (IO) compared to CT. This study compares real-world treatment patterns and outcomes between CT and IO administrations in second-line (2L) settings for patients with stage IV NSCLC. MATERIALS AND METHODS This retrospective study included patients in the United States Department of Veterans Affairs healthcare system diagnosed with stage IV NSCLC during 2012-2017 and receiving IO or CT in the 2L. Patient demographics and clinical characteristics, healthcare resource utilization (HCRU), and adverse events (AEs) were compared between treatment groups. Logistic regression was used to examine differences in baseline characteristics between groups, and inverse probability weighting multivariable Cox proportional hazard regression was used to analyze OS. RESULTS Among 4,609 Veterans who received first-line (1L) therapy for stage IV NSCLC, 96% received 1L CT alone. A total of 1,630 (35%) were administered 2L systemic therapy, with 695 (43%) receiving IO and 935 (57%) receiving CT. Median age was 67 years (IO group) and 65 years (CT group); most patients were male (97%) and white (76-77%). Patients administered 2L IO had a higher Charlson Comorbidity Index than those administered CT (p = 0.0002). 2L IO was associated with significantly longer OS compared with CT (hazard ratio 0.84, 95% CI 0.75-0.94). IO was more frequently prescribed during the study period (p < 0.0001). No difference in rate of hospitalizations was observed between the two groups. CONCLUSIONS Overall, the proportion of advanced NSCLC patients receiving 2L systemic therapy is low. Among patients treated with 1L CT and without IO contraindications, 2L IO should be considered, as this supports potential benefit of IO for advanced NSCLC. The increasing availability and indications for IO will likely increase the administration of 2L therapy to NSCLC patients.
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Affiliation(s)
- Christina D. Williams
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States of America
- Medical Oncology, Department of Medicine, Duke University, Durham, North Carolina, United States of America
- * E-mail:
| | - Mina A. Allo
- Bristol-Myers Squibb Company, US Health Economics and Outcomes Research, Princeton, New Jersey, United States of America
| | - Lin Gu
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States of America
- Duke Cancer Institute, Biostatistics Shared Resource, Duke University, Durham, North Carolina, United States of America
| | - Vishal Vashistha
- Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Division of Hematology-Oncology, Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States of America
| | - Ashlyn Press
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States of America
| | - Michael Kelley
- Medical Oncology, Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Division of Hematology-Oncology, Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States of America
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Shalata W, Weissmann S, Itzhaki Gabay S, Sheva K, Abu Saleh O, Jama AA, Yakobson A, Rouvinov K. A Retrospective, Single-Institution Experience of Bullous Pemphigoid as an Adverse Effect of Immune Checkpoint Inhibitors. Cancers (Basel) 2022; 14:cancers14215451. [PMID: 36358869 PMCID: PMC9656349 DOI: 10.3390/cancers14215451] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
Simple Summary This article investigates the cutaneous adverse immune effects induced by immune checkpoint inhibitors. These drugs target proteins expressed on cancer cells that aid in the avoidance of immune system detection and destruction. Immune checkpoint inhibitors inadvertently cause other immune-mediated adverse effects. Cutaneous toxicities are the commonest adverse effect from immunotherapy; furthermore, they are usually developed early in the course of treatment. A rare and severe cutaneous adverse event is Bullous Pemphigoid. This article investigates the average and median onset of these drug toxicities, as well as treatments. We found these side effects to be negatively skewed, indicating most cases occur several months into treatment. Abstract Immune checkpoint inhibitors are a class of cancer treatment drugs that stimulate the immune system’s ability to fight tumor cells. These drugs are monoclonal antibodies targeting im-mune-inhibiting proteins on cancer cells, such as CTLA-4 and PD-1/PD-L1. Immune checkpoint inhibitors cause many immune-related adverse events. Cutaneous toxicities are of the most common adverse effects and occur with a range of severity. Bullous Pemphigoid is a rare adverse event with a high impact on quality of life that may occur after immune checkpoint inhibitor treatment. In this article, we investigate current research on immune checkpoint inhibitors, cutaneous adverse events, and common presentations and treatments, with a specific focus on Bullous Pemphigoid, its characteristics, onset timing, and treatment. Significant findings include a negative skew in the onset of presentation. Furthermore, we describe exclusive cases.
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Affiliation(s)
- Walid Shalata
- The Legacy Heritage Center & Dr. Larry Norton Institute, Soroka Medical Center and Ben Gurion University, Beer Sheva 84105, Israel
- Correspondence: ; Tel.: +972-(0)54-296-7100
| | - Sarah Weissmann
- Medical School for International Health, Ben Gurion University of the Negev, Beer Sheva 84105, Israel
| | - Sapir Itzhaki Gabay
- Department of Dermatology, Soroka Medical Center and Ben Gurion University, Beer Sheva 84105, Israel
| | - Kim Sheva
- The Legacy Heritage Center & Dr. Larry Norton Institute, Soroka Medical Center and Ben Gurion University, Beer Sheva 84105, Israel
| | - Omar Abu Saleh
- Department of Dermatology and Venereology, Emek Medical Centre, Afula 18341, Israel
| | - Ashraf Abu Jama
- The Legacy Heritage Center & Dr. Larry Norton Institute, Soroka Medical Center and Ben Gurion University, Beer Sheva 84105, Israel
| | - Alexander Yakobson
- The Legacy Heritage Center & Dr. Larry Norton Institute, Soroka Medical Center and Ben Gurion University, Beer Sheva 84105, Israel
| | - Keren Rouvinov
- The Legacy Heritage Center & Dr. Larry Norton Institute, Soroka Medical Center and Ben Gurion University, Beer Sheva 84105, Israel
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10
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Wu Y, Li D, Wu M, Yang Y, Shen M, Chen K. Peripheral absolute eosinophil count identifies the risk of serious immune-related adverse events in non-small cell lung cancer. Front Oncol 2022; 12:1004663. [PMID: 36313675 PMCID: PMC9608122 DOI: 10.3389/fonc.2022.1004663] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/29/2022] [Indexed: 12/02/2022] Open
Abstract
Background Immune-related adverse events (irAEs) have drawn a lot of attention lately as a result of the predominance of immunotherapy in advanced non-small cell lung cancer (NSCLC). However, the clinical evidence for irAEs in real life is limited. In this paper, the occurrence of irAEs in Chinese NSCLC patients was examined, and possible risk factors for the emergence of severe irAEs were discovered. Methods Our retrospective investigation assessed the occurrence of adverse events (AEs) and prognosis of 213 patients who received immunotherapy for NSCLC. Using univariate and multivariate logistic regression models, the association between clinicopathological traits and the incidence of severe irAEs was investigated. To assess the prognostic impact of irAEs, survival data was analyzed. Results Among the 213 NSCLC patients, 122 (57.3%) had irAEs of any grade, and 38 (17.8%) had high-grade (grade 3-5) AEs. Baseline peripheral absolute eosinophil count (AEC) (HR 6.58, 95% CI: 1.5-28.8, P=0.012) was found to be an independent predictor of high-grade irAEs by multivariate analysis. The survival analysis revealed that patients with severe irAEs had worse OS (15.7 vs. 20.8 months, 95% CI: 11.6-19.8 vs. 16.0-25.5, P=0.026). Conclusion According to our findings, the peripheral absolute eosinophil count (AEC) is a reliable indicator of severe irAEs in NSCLC. Serious irAEs that occur in patients often reflect poor prognoses. In the future, high-grade irAEs should receive more attention.
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Affiliation(s)
| | | | | | | | - Meng Shen
- *Correspondence: Kai Chen, ; Meng Shen,
| | - Kai Chen
- *Correspondence: Kai Chen, ; Meng Shen,
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11
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Basak EA, Vermeer NS, de Joode K, Hurkmans DP, Velthuis DEM, Oomen-de Hoop E, Schreurs MWJ, Bins S, Koolen SLW, Debets R, van der Veldt AAM, Aerts JGJV, Joosse A, Mathijssen RHJ. Associations between patient and disease characteristics and severe adverse events during immune checkpoint inhibitor treatment: An observational study. Eur J Cancer 2022; 174:113-120. [PMID: 35988409 DOI: 10.1016/j.ejca.2022.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/10/2022] [Accepted: 07/12/2022] [Indexed: 12/17/2022]
Abstract
AIM With increasing use of immune checkpoint inhibitors (ICIs) more patients will develop severe and potentially life-threatening immune-related adverse events (irAEs). So far, predictive models for the occurrence of grade ≥3 irAEs are lacking. Therefore, we analysed associations between patient and disease characteristics, and the occurrence of grade ≥3 irAEs. METHODS Patients with cancer who were treated with anti-PD-1 (+/-anti-CTLA-4) between July 2015 and February 2020, and who were prospectively included in the MULTOMAB-trial, were eligible for this cohort study. Time to and occurrence of grade ≥3 irAEs according to CTCAE v5.0 were retrospectively registered. The associations between patient and disease characteristics and irAE occurrence were analysed using the competing risk cox-regression model of Fine and Gray. Analyses were performed separately in patients treated with monotherapy (anti-PD-1) and combination therapy (anti-PD-1 + anti-CTLA-4). Subgroup analyses were performed in tumour types with the highest number of patients; melanoma and NSCLC. RESULTS Out of 641 patients, 106 patients (17%) experienced grade ≥3 irAEs. None of the analysed factors were associated with grade ≥3 irAE occurrence in the monotherapy (n = 550) or the combination therapy (n = 91) groups, nor in the subgroup analyses. Of interest, none of the patients with NSCLC with a WHO performance status of 0 (n = 34) experienced grade ≥3 irAEs. Most common NSCLC histology types were adenocarcinoma (n = 99/55%) and squamous cell carcinoma (n = 39/22%). CONCLUDING STATEMENT This study shows that patient and disease characteristics are not able to predict the occurrence of serious AEs in patients treated with ICIs.
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Affiliation(s)
- Edwin A Basak
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - Niels S Vermeer
- Dept. of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Karlijn de Joode
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Daan P Hurkmans
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Dorian E M Velthuis
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Esther Oomen-de Hoop
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Marco W J Schreurs
- Dept. of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sander Bins
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Stijn L W Koolen
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Dept. of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Reno Debets
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Astrid A M van der Veldt
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Dept. of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joachim G J V Aerts
- Dept. of Pulmonology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Arjen Joosse
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Ron H J Mathijssen
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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12
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Wang J, Dasari S, Elantably D, Alkrekshi A, Kim YD. Use of PD-1 inhibitors in patients with end-stage renal disease: safety and clinical outcomes from real-world data. Acta Oncol 2022; 61:1157-1161. [PMID: 36173299 DOI: 10.1080/0284186x.2022.2127121] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Jiasheng Wang
- Department of Hematology and Oncology, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Srilatha Dasari
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Dina Elantably
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Akram Alkrekshi
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Yeseong David Kim
- Section of Gastroenterology, Department of Medicine, Temple University, Philadelphia, PA, USA
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13
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Hao Y, Zhang X, Yu L. Immune checkpoint inhibitor-related pneumonitis in non-small cell lung cancer: A review. Front Oncol 2022; 12:911906. [PMID: 36052257 PMCID: PMC9424849 DOI: 10.3389/fonc.2022.911906] [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: 04/03/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have shown definite therapeutic effects in various types of cancers, especially non-small cell lung cancer (NSCLC). However, ICIs have unique side effects, called immune-related adverse events (irAEs), which can occur in various systems throughout the body. Among such irAEs, immune checkpoint inhibitor-related pneumonitis (ICI-P) is a fatal adverse reaction. In this review, we discussed the risk factors, pathogenesis, clinical characteristics, radiological manifestations, pathological features, diagnosis, grading, and management of ICI-P in NSCLC and the relationship between ICI-P and the efficacy of ICI therapy. In addition, we discussed the predictive factors for ICI-P. This review will play a crucial role in the prediction, evaluation, and management of ICI-P for widespread application of immunotherapy.
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14
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Hsu ML, Murray JC, Psoter KJ, Zhang J, Barasa D, Brahmer JR, Ettinger DS, Forde PM, Hann CL, Lam VK, Levy B, Marrone KA, Patel T, Peterson V, Sagorsky S, Turner M, Anagnostou V, Naidoo J, Feliciano JL. Clinical Features, Survival, and Burden of Toxicities in Survivors More Than One Year After Lung Cancer Immunotherapy. Oncologist 2022; 27:971-981. [PMID: 35972337 PMCID: PMC9632301 DOI: 10.1093/oncolo/oyac140] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/01/2022] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Anti-PD-(L)1 immune checkpoint inhibitors (ICI) improve survival in patients with advanced non-small cell lung cancer (aNSCLC). The clinical features, survival, and burden of toxicities of patients with aNSCLC alive >1 year from ICI initiation are poorly understood. MATERIALS AND METHODS We defined ICI survivors as patients alive >1 year after ICI start and retrospectively reviewed demographics, treatment, and immune-related adverse events (irAEs). Long-term irAEs were defined as ongoing irAEs lasting >1 year; burden of toxicity measures were based on percentage of days a patient experienced toxicity. Using linear and logistic regression, we evaluated association between demographics and disease characteristics with burden of toxicity. RESULTS We identified 114 ICI survivors from 317 patients with aNSCLC. Half (52%) experienced an irAE of any grade, and 23.7% developed long-term irAEs. More ICI survivors with irAES in the first year had never smoked (P = .018) or received ICIs as frontline therapy (P = .015). The burden of toxicity in the first year significantly correlated with the burden of toxicity afterward (ρ = 0.72; P < .001). No patients with progressive disease had a high burden of toxicity, and they experienced 30.6% fewer days with toxicity than those with stable disease. Increased duration of therapy was associated with higher odds of experiencing toxicity. Half of ICI survivors with irAEs were still receiving treatment for unresolved irAEs at time of death or last follow-up. CONCLUSION Significant proportions of ICI survivors have unresolved long-term toxicities. These data support a growing need to understand long-term toxicity to optimize management of those treated with ICIs.
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Affiliation(s)
| | - Joseph C Murray
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Kevin J Psoter
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Jiajia Zhang
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Durrant Barasa
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Julie R Brahmer
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - David S Ettinger
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Patrick M Forde
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Christine L Hann
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Vincent K Lam
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Benjamin Levy
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Kristen A Marrone
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | | | | | | | - Michelle Turner
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Valsamo Anagnostou
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA,Bloomberg-Kimmel institute for Cancer Immunotherapy, Baltimore, MD, USA
| | | | - Josephine L Feliciano
- Corresponding author: Josephine Feliciano, MD, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Bayview, 301 Mason Lord Drive, Baltimore, MD 21224, USA. Tel: +1 410 550 1711; Fax: +1 410 550 1116.
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15
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Xu Y, Lyu X, Qin Y, Ma D, Wang M, Shi J, Long Y, Tang B, Liu H. Multi-organs perioperative immune-related adverse events and postoperative bronchial anastomotic fistula in a patient receiving neoadjuvant immunotherapy with NSCLC. Thorac Cancer 2022; 13:2340-2345. [PMID: 35815431 PMCID: PMC9376172 DOI: 10.1111/1759-7714.14567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 06/16/2022] [Indexed: 12/18/2022] Open
Abstract
The safety of neoadjuvant chemoimmunotherapy before surgery in patients with non–small cell lung cancer (NSCLC) remains unclear in the perioperative stage. We describe a case of a 63‐year‐old man with IIIC stage NSCLC who received neoadjuvant chemoimmunotherapy and radical lobectomy. After the second cycle of pembrolizumab and chemotherapy (paclitaxel + carboplatin), the patient was diagnosed with immunologic enterocolitis and relieved by glucocorticoid therapy. Radical lobectomy of the right upper lobe was then performed. On postoperative day 4 (POD 4), the patient suddenly suffered suffocated wheezing during sleep. Interstitial lung disease was, therefore, identified by chest computed tomography scan. Glucocorticoids and mechanical ventilation were applied and the symptoms were relieved. On POD 10, the patient developed a bronchial fistula and underwent emergent repair surgery. This is the first case of multi‐organs, multi‐time point immune‐related adverse events (irAE) in perioperative NSCLC patients who received neoadjuvant chemoimmunotherapy. Clinicians should be on high alert for signs of irAEs in neoadjuvant chemoimmunotherapy patients, promptly requiring multidisciplinary management.
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Affiliation(s)
- Yuan Xu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Xiaohong Lyu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China.,Eight-Year Program of Clinical Medicine, Peking Union Medical College, Beijing, China
| | - Yingzhi Qin
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Dongjie Ma
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Mengzhao Wang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Juhong Shi
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Tang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
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16
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Tiu BC, Zubiri L, Iheke J, Pahalyants V, Theodosakis N, Ugwu-Dike P, Seo J, Tang K, Sise ME, Sullivan R, Naidoo J, Mooradian MJ, Semenov YR, Reynolds KL. Real-world incidence and impact of pneumonitis in patients with lung cancer treated with immune checkpoint inhibitors: a multi-institutional cohort study. J Immunother Cancer 2022; 10:e004670. [PMID: 35705313 PMCID: PMC9204442 DOI: 10.1136/jitc-2022-004670] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have improved survival and are increasingly used for non-small cell lung cancer. However, use may be limited by immune-related adverse events such as checkpoint-inhibitor pneumonitis (CIP). Literature estimates for CIP incidence are inconsistent. Real-world adherence to guidelines, clinical course, and healthcare utilization in the treatment of CIP has not been described in large cohorts. METHODS A combined claims and electronic health record database (TriNetX) was used to identify 13,113 patients with lung cancer treated with programmed cell death receptor/ligand 1 (PD-1/PD-L1) inhibitors, and a propensity score-matched control cohort treated with chemotherapy or targeted therapies. The attributable risk of CIP was calculated in the first 12 months after therapy by comparing the incidence of diagnosis codes for pneumonitis/pneumonia between cohorts. Cases of CIP, identified by the most specific code for drug-induced respiratory conditions, were further analyzed for medication usage, rates of diagnostic bronchoscopy, ICI discontinuation rates, and usage of hospital services compared with patients receiving PD-1/PD-L1 inhibitors who did not develop CIP. RESULTS The attributable risk of pneumonitis to PD-1/PD-L1 inhibitors was 2.49% (95% CI, 1.50% to 3.47%). Median time to onset in the CIP subcohort was 3.9 months (IQR, 2.1-7.3 months). Steroid and antibiotic use increased dramatically after a pneumonitis diagnosis, and 70.2% of patients permanently discontinued ICI therapy. Compared with controls, patients with CIP had more than a threefold increased risk of needing critical care (relative risk 3.59, 95% CI, 2.31 to 5.57) and an increased risk of mortality (HR 2.34, 95% CI, 1.47 to 3.71). CONCLUSIONS In a large claims-based analysis, PD-1/PD-L1 inhibitors increase the risk of pneumonitis in patients with lung cancer by 2.49%. Cases of CIP are associated with high healthcare utilization, discontinuation of ICIs, and mortality.
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Affiliation(s)
- Bruce C Tiu
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leyre Zubiri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James Iheke
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vartan Pahalyants
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicholas Theodosakis
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pearl Ugwu-Dike
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jayhyun Seo
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kimberly Tang
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan Sullivan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jarushka Naidoo
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Beaumont RCSI Cancer Centre, Beaumont Hospital and the RCSI University of Health Sciences, Dublin, Ireland
| | - Meghan J Mooradian
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yevgeniy R Semenov
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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17
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Skribek M, Rounis K, Tsakonas G, Ekman S. Complications following novel therapies for non-small cell lung cancer. J Intern Med 2022; 291:732-754. [PMID: 35032058 DOI: 10.1111/joim.13445] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The emergence of tyrosine kinase inhibitors and immune checkpoint inhibitors has paved a new era for the management of non-small cell lung cancer, which has for many years lacked major clinical breakthroughs. Historically, 5-year overall survival remained below 5% in individuals with metastatic disease. These novel treatments have led to significant prolongation of survival in the locally advanced and metastatic setting, exceeding 25% in selected populations. However, they present new challenges to clinicians due to their inherently different spectrum of toxicity unique to each specific drug's pharmacodynamic profile. Internists commonly come across these side effects in their daily clinical practice. Their optimal recognition and management are of utmost importance, because it is associated with significant improvements in patient survival outcomes and their quality of life. The aim of this review is to summarize the complications following these novel treatments for non-small cell lung cancer.
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Affiliation(s)
- Marcus Skribek
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Konstantinos Rounis
- Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Tsakonas
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Simon Ekman
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
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The Role of Myeloid Cells in Hepatotoxicity Related to Cancer Immunotherapy. Cancers (Basel) 2022; 14:cancers14081913. [PMID: 35454819 PMCID: PMC9027811 DOI: 10.3390/cancers14081913] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 11/23/2022] Open
Abstract
Simple Summary Immune-modulating cancer treatments have proved to be highly effective in a wide range of tumour types. They interrupt the usual communication between cells in the immune system, encouraging them to become more active in identifying and destroying cancer cells. Although these therapies are very successful in treating cancer, patients frequently experience liver injury as a side effect related to over activation of the immune system. If cancer patients develop this side effect, they need to stop their cancer therapy and be given strong immunosuppressants. Researchers are now working on understanding the mechanisms involved in the development of liver inflammation. In this review we will summarise findings identifying classes of immune cells that are of particular importance in this context and highlight ways in which we can use this knowledge to improve the safety of these new cancer drugs. Abstract Drug-related hepatotoxicity is an emerging clinical challenge with the widening use of immunotherapeutic agents in the field of oncology. This is an important complication to consider as more immune oncological targets are being identified to show promising results in clinical trials. The application of these therapeutics may be complicated by the development of immune-related adverse events (irAEs), a serious limitation often requiring high-dose immunosuppression and discontinuation of cancer therapy. Hepatoxicity presents one of the most frequently encountered irAEs and a better understanding of the underlying mechanism is crucial for the development of alternative therapeutic interventions. As a novel drug side effect, the immunopathogenesis of the condition is not completely understood. In the liver, myeloid cells play a central role in the maintenance of homeostasis and promotion of inflammation. Recent research has identified myeloid cells to be associated with hepatic adverse events of various immune modulatory monoclonal antibodies. In this review article, we provide an overview of the role of myeloid cells in the immune pathogenesis during hepatoxicity related to cancer immunotherapies and highlight potential treatment options.
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19
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Stabellini N, Bruno DS, Dmukauskas M, Barda AJ, Cao L, Shanahan J, Waite K, Montero AJ, Barnholtz-Sloan JS. Sex differences in lung cancer treatment and outcomes at a large hybrid academic-community practice. JTO Clin Res Rep 2022; 3:100307. [PMID: 35400080 PMCID: PMC8983352 DOI: 10.1016/j.jtocrr.2022.100307] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 11/02/2022] Open
Abstract
Introduction Methods Results Conclusions
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20
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Immune Checkpoint Inhibitors-Associated Cardiotoxicity. Cancers (Basel) 2022; 14:cancers14051145. [PMID: 35267453 PMCID: PMC8909315 DOI: 10.3390/cancers14051145] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 12/19/2022] Open
Abstract
Large population-based studies examining differences in ICI-associated cardiotoxicity across cancer types and agents are limited. Data of 5518 cancer patients who received at least one cycle of ICIs were extracted from a large network of health care organizations. ICI treatment groups were classified by the first ICI agent(s) (ipilimumab, nivolumab, pembrolizumab, cemiplimab, avelumab, atezolizumab, or durvalumab) or its class (PD-1 inhibitors, PD-L1 inhibitors, CTLA4-inhibitors, or their combination (ipilimumab + nivolumab)). Time to first cardiac adverse event (CAE) (arrhythmia, acute myocardial infarction, myocarditis, cardiomyopathy, or pericarditis) developed within one year after ICI initiation was analyzed using a competing-risks regression model adjusting for ICI treatment groups, patient demographic and clinical characteristics, and cancer sites. By month 12, 12.5% developed cardiotoxicity. The most common cardiotoxicity was arrhythmia (9.3%) and 2.1% developed myocarditis. After adjusting for patient characteristics and cancer sites, patients who initiated on monotherapy with ipilimumab (adjusted Hazard Ratio (aHR): 2.00; 95% CI: 1.49−2.70; p < 0.001) or pembrolizumab (aHR: 1.21; 95% CI: 1.01−1.46; p = 0.040) had a higher risk of developing CAEs within one year compared to nivolumab monotherapy. Ipilimumab and pembrolizumab use may increase the risk of cardiotoxicity compared to other agents. Avelumab also estimated a highly elevated risk (aHR: 1.92; 95% CI: 0.85−4.34; p = 0.117) compared to nivolumab and other PD-L1 agents, although the estimate did not reach statistical significance, warranting future studies.
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21
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Harnessing big data to characterize immune-related adverse events. Nat Rev Clin Oncol 2022; 19:269-280. [PMID: 35039679 DOI: 10.1038/s41571-021-00597-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 12/17/2022]
Abstract
Immune-checkpoint inhibitors (ICIs) have transformed patient care in oncology but are associated with a unique spectrum of organ-specific inflammatory toxicities known as immune-related adverse events (irAEs). Given the expanding use of ICIs, an increasing number of patients with cancer experience irAEs, including severe irAEs. Proper diagnosis and management of irAEs are important to optimize the quality of life and long-term outcomes of patients receiving ICIs; however, owing to the substantial heterogeneity within irAEs, and despite multicentre initiatives, performing clinical studies of these toxicities with a sufficient cohort size is challenging. Pioneering studies from the past few years have demonstrated that aggregate clinical data, real-world data (such as data on pharmacovigilance or from electronic health records) and multi-omics data are alternative tools well suited to investigating the underlying mechanisms and clinical presentations of irAEs. In this Perspective, we summarize the advantages and shortcomings of different sources of 'big data' for the study of irAEs and highlight progress made using such data to identify biomarkers of irAE risk, evaluate associations between irAEs and therapeutic efficacy, and characterize the effects of demographic and anthropometric factors on irAE risk. Harnessing big data will accelerate research on irAEs and provide key insights that will improve the clinical management of patients receiving ICIs.
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Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: A Systematic Review. Cancers (Basel) 2021; 13:cancers13205218. [PMID: 34680365 PMCID: PMC8534225 DOI: 10.3390/cancers13205218] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary This review article addresses the toxic effects on the heart associated with the use of certain cancer-treating drugs known as immune checkpoint inhibitors. These drugs target specific proteins in the cell cycle that are abundantly expressed in cancerous cells; however, they inadvertently damage non-cancerous tissue. In the heart, this occurs in the form of dysfunction or death of smooth muscle cells, leading to consequences such as infection, heart rhythm changes, and hormonally dependent and independent ischemia. This review examines the average and median onset of these drug toxicities as well as antidotes. One key observation is that these side effects are positively skewed, meaning they occur early in cancer treatment. Abstract Immune checkpoint inhibitors are immune stimulatory drugs used to treat many types of cancer. These drugs are antibodies against inhibitory proteins, such as CTLA-4 and PD-1/PD-L1, that are expressed on immune cells. When bound, they allow for increased stimulation of T cells to fight tumor cells. However, immune checkpoint inhibitors have several immune-related adverse effects. Many cases have come to light recently of cardiotoxicity as a result of treatment with these drugs. Cardiotoxicity from immune checkpoint inhibitors is unique due to its rarity and high mortality rate. Patients with this toxicity may present with myocarditis, pericarditis, Takotsubo cardiomyopathy, conduction disorders, and others within just a few weeks of starting immune checkpoint inhibitors. We present here a review of the current research on immune checkpoint inhibitors, their associated cardiotoxicities, the timing of presentation of these conditions, lab tests and histology for each condition, and finally the treatment of patients with cardiotoxicity. We observe a positive skew in the onset of presentation, which is significant for the treating physician.
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Miller AR, Manser R. The knowns & unknowns of pulmonary toxicity following immune checkpoint inhibitor therapies: a narrative review. Transl Lung Cancer Res 2021; 10:2752-2765. [PMID: 34295675 PMCID: PMC8264318 DOI: 10.21037/tlcr-20-806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/05/2020] [Indexed: 11/29/2022]
Abstract
Since their discovery immune checkpoint inhibitors (ICI) have dramatically changed the treatment landscape for many cancers. In addition to their efficacy they are generally well tolerated, however, they have led to a new range of immune-related adverse events (irAEs) including pneumonitis. While not the most frequently reported immune-related adverse event in the clinical trial setting, recent real-world data suggests a significantly higher rate of pneumonitis leading to treatment suspension or cessation. It also appears to disproportionately contribute to immune-related mortality, particularly with anti-PD-1/PD-L1 treatment. While indicators have emerged regarding risk factors, incomplete prospective recording of patient characteristics hampers strong conclusions. Presenting symptoms are non-specific and the differential diagnosis is broad, made more complex by concomitant treatment with traditional chemotherapy or radiotherapy. Radiological findings are diverse and inconsistent terminology makes comparison and more complete characterization difficult. Further, little is known about the role of baseline testing or surveillance for early detection of pneumonitis, or the real-world role of bronchoscopy or biopsy in assessment. Scant literature exists to direct these complex decisions, so treatment guidelines have been published based on expert consensus. Here we provide a narrative review of what is known about ICI pneumonitis and propose key questions to enhance our understanding into the future.
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Affiliation(s)
- Alistair R Miller
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Victoria, Australia.,Department of Internal Medicine, Peter MacCallum Cancer Centre, Victoria, Australia.,Department of Medicine, Monash Health, Monash University, Victoria, Australia
| | - Renee Manser
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Victoria, Australia.,Department of Internal Medicine, Peter MacCallum Cancer Centre, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia
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Huber RM, Kauffmann-Guerrero D, Hoffmann H, Flentje M. New developments in locally advanced nonsmall cell lung cancer. Eur Respir Rev 2021; 30:30/160/200227. [PMID: 33952600 DOI: 10.1183/16000617.0227-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022] Open
Abstract
Locally advanced nonsmall cell lung cancer, due to its varying prognosis, is grouped according to TNM stage IIIA, IIIB and IIIC. Developments over the last 3 years have been focused on the integration of immunotherapy into the combination treatment of a locally definitive therapy (surgery or radiotherapy) and chemotherapy. For concurrent chemoradiotherapy, consolidation therapy with durvalumab was established. Adjuvant targeted therapy has again gained increasing interest. In order to adapt treatment to the specific stage subgroup and its prognosis, fluorodeoxyglucose positron emission tomography/computed tomography and pathological evaluation of the mediastinum are important. Tumours should be investigated for immunological features and driver mutations. Regarding toxicity, evaluation of pulmonary and cardiac function, as well as symptoms and quality of life, is of increasing importance. To improve the management and prognosis of this heterogeneous entity, clinical trials and registries should take these factors into account.
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Affiliation(s)
- Rudolf M Huber
- Division of Respiratory Medicine and Thoracic Oncology, Dept of Medicine, University of Munich - Campus Innenstadt, Comprehensive Pneumology Center Munich (CPC-M) and Thoracic Oncology Centre Munich, Munich, Germany .,Member of the German Centre of Lung Research
| | - Diego Kauffmann-Guerrero
- Division of Respiratory Medicine and Thoracic Oncology, Dept of Medicine, University of Munich - Campus Innenstadt, Comprehensive Pneumology Center Munich (CPC-M) and Thoracic Oncology Centre Munich, Munich, Germany.,Member of the German Centre of Lung Research
| | - Hans Hoffmann
- Division of Thoracic Surgery, Technical University of Munich, Munich, Germany
| | - Michael Flentje
- Dept of Radiation Oncology and Palliative Medicine, University of Würzburg, Würzburg, Germany
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Adam K, Iuga A, Tocheva AS, Mor A. A novel mouse model for checkpoint inhibitor-induced adverse events. PLoS One 2021; 16:e0246168. [PMID: 33571254 PMCID: PMC7877613 DOI: 10.1371/journal.pone.0246168] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 01/14/2021] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors have demonstrated significant efficacy in the treatment of a variety of cancers, however their therapeutic potential is limited by abstruse immune related adverse events. Currently, no robust animal model exists of checkpoint inhibitor-induced adverse events. Establishing such a model will improve our mechanistic understanding of this process, which in turn will inform design of improved therapies. We developed a mouse model to determine inflammatory toxicities in response to dual checkpoint blockade in the presence of syngeneic tumors. Mice from susceptible genetic backgrounds received intraperitoneal injections of anti-mouse PD-1 and CTLA-4 antibodies. The mice were monitored for weight loss and histologic evidence of inflammation. Blood was collected for basic metabolic panels and titers of anti-nuclear antibodies. In parallel, mice were also treated with prednisolone, which is commonly used to treat immune related adverse events among cancer patients. Among all the genetic backgrounds, B6/lpr mice treated with anti-CTLA-4 and anti-PD-1 antibodies developed more substantial hepatitis, pancreatitis, colitis, and pneumonitis characterized by organ infiltration of immune cells. Mice that developed tissue infiltration demonstrated high serum levels of glucose and high titers of anti-nuclear antibodies. Finally, while administration of prednisolone prevented the development of the inflammatory adverse events, it also abrogated the protective anti-tumor effect of the checkout inhibitors. Genetic background and treatment modalities jointly modified the inflammatory adverse events in tumor bearing mice, suggesting a complex mechanism for checkpoint inhibitor-related inflammation. Future studies will assess additional genetic susceptibility factors and will examine possible contributions from the administration of other anti-inflammatory drugs.
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Affiliation(s)
- Kieran Adam
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York, United States of America
| | - Alina Iuga
- Department of Pathology, Columbia University Medical Center, New York, New York, United States of America
| | - Anna S. Tocheva
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York, United States of America
| | - Adam Mor
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York, United States of America
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DaCosta Byfield S, Chastek B, Korrer S, Horstman T, Malin J, Newcomer L. Real-World Outcomes and Value of First-Line Therapy for Metastatic Non-Small Cell Lung Cancer †. Cancer Invest 2020; 38:608-617. [PMID: 33107767 DOI: 10.1080/07357907.2020.1827415] [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: 10/23/2022]
Abstract
Although physicians rely on clinical trial data to guide cancer treatment decisions, patient characteristics and outcomes often differ between real-world and clinical trial populations. We analyzed retrospective clinical data collected from a prior authorization (PA) tool linked with payer claims data to describe outcomes of first-line treatment for metastatic non-small cell lung cancer among 2,108 patients. Duration of therapy was shorter than observed in clinical trials. Healthcare costs and hospitalizations varied substantially by regimen. PA clinical data linked with administrative claims enable head-to-head comparisons of contemporary cancer treatments used in routine clinical practice, which are not available from clinical trials.
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Affiliation(s)
| | | | | | | | | | - Lee Newcomer
- Lee N. Newcomer Consulting, LLC, Minneapolis, Minnesota, USA
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