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Lee CM, Wang M, Rajkumar A, Calabrese C, Calabrese L. A scoping review of vasculitis as an immune-related adverse event from checkpoint inhibitor therapy of cancer: Unraveling the complexities at the intersection of immunology and vascular pathology. Semin Arthritis Rheum 2024; 66:152440. [PMID: 38579593 DOI: 10.1016/j.semarthrit.2024.152440] [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: 12/11/2023] [Revised: 03/05/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND/PURPOSE Vasculitis as an immune-related adverse event (irAE) from checkpoint inhibitor therapy (ICI) to treat cancer is a rare clinical event, and little is known regarding its nosology, clinical manifestations, or response to treatment and outcomes. METHODS To address these gaps, we used the Preferred Reporting Items for Systemic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework to further define this complication. Two independent PUBMED searches in September and November of 2022 revealed 127 publications with 37 excluded from title by relevance, 43 excluded by article type, and 23 excluded due to lack of biopsy results, or biopsy negative for vasculitis. Twenty-nine documented cases from 24 publications were included for final analysis. Basic demographics, ICI details, timing of onset of vasculitis symptoms, irAE treatment and outcomes were collected. The vasculitides were classified using 2022 ACR/EULAR Vasculitis Classification Criteria as well as 2012 Revised Chapel-Hill Nomenclature. Adaptations from Naidoo et al. 2023 [1] consensus definitions for irAEs were used and efforts were made to classify steroid-responsive versus unresponsive irAEs. RESULTS Of the 29 cases reviewed, the average age of patients was 62.1 ± 11.0, composed of 58.6 % (n = 17) male and 41.3 % (n = 12) female. Prominent cancer types were lung cancer (41.4 %; n = 12), melanoma (41.4 %; n = 12), and renal cancer (10.3 %; n = 3), with majority being stage 4 (75.9 %, n = 22) and stage 3 (10.3 %, n = 3). Only 8 cases met the ACR/EULAR criteria, and by Chapel-Hill Nomenclature, approximately a third were small-vessel vasculitis (31.0 %; n = 9) with n = 4 positive for ANCA. Most biopsies were taken from the skin (37.9 %, n = 11) and kidney (24.1 %, n = 7). Patients were either treated with single (65.5 %, n = 19), dual (17.2 %; n = 5), or sequential (17.2 %; n = 5) ICI regimen which included anti-PD-1 therapy in all but one case, with mean of 8.7 ± 10.5 cycles received. Mean time to onset of symptoms from start of ICI was 7.2 ± 7.8 months, with 55.2 % occurring >3 months since the initial immunotherapy. Vasculitis treatment included glucocorticoids in 96 % of cases and immunotherapy was often discontinued (44.8 %; n = 13). Clinical improvement of irAE was documented in 86.2 % (n = 25). Data were missing in terms of fate of ICI (34.5 %; n = 10) and tumor outcomes (41.4 %; n = 12). Cancer progressed in 20.7 % (n = 6), stable in 34.5 % (n = 10) cases, and 6 patients died of all-causes. CONCLUSION Vasculitis as an irAE appears clinically heterogeneous and rare. Among reported cases with adequate documentation, vasculitis is of delayed onset following the initiation of immunotherapy. Outcomes of ICI-vasculitis were generally favorable, responding to glucocorticoids and immunotherapy withdrawal. There is an urgent need for more standardized reporting of rare irAEs such as vasculitis to clarify clinical risks, classification, relationship to immunotherapy and outcomes.
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Affiliation(s)
- Chan-Mi Lee
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Margaret Wang
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Aarthi Rajkumar
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Cassandra Calabrese
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States
| | - Leonard Calabrese
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States.
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Chabannes M, Lisri Z, Lang S, Seibel J, Eberst G, Ducloux D, Pursun C, Durey MAD, Alyanakia MA, Felix S, Crepin T. Immune checkpoint inhibitor therapy associated with IgA nephropathy: a case report and literature review. Front Immunol 2024; 15:1393901. [PMID: 38807591 PMCID: PMC11130422 DOI: 10.3389/fimmu.2024.1393901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/30/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) dramatically improve the prognosis of many malignancies but at the cost of numerous side effects, which may limit their benefits. Acute kidney injury associated with immune checkpoint inhibitors most frequently are acute tubulointerstitial nephritis (ATIN), but various cases of glomerulonephritis have also been reported. Herein, we report a case of severe IgA nephropathy (IgAN) associated with ICIs and carry out a literature review. IgAN was diagnosed in a median time of 5 months (range 1-12 months) after the initiation of ICIs, with heterogeneous severity, and usually treated by corticosteroid and discontinuation of ICIs. In contrast to our case, renal outcomes in literature were often favorable, with recovery of renal function and a reduction in proteinuria on treatment. Although IgAN related to ICIs is a much rarer complication than ATIN, it may still be underdiagnosed. Careful questioning and screening for asymptomatic hematuria should be performed before using ICIs.
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Affiliation(s)
- Melchior Chabannes
- University Hospital, Besançon, Department of Nephrology, Dialysis and Renal Transplantation, Besancon, France
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
| | - Ziriab Lisri
- University Hospital, Besançon, Department of Nephrology, Dialysis and Renal Transplantation, Besancon, France
| | - Stéphane Lang
- University Hospital, Besançon, Department of Nephrology, Dialysis and Renal Transplantation, Besancon, France
| | - Jean Seibel
- University Hospital, Besançon, Department of Nephrology, Dialysis and Renal Transplantation, Besancon, France
| | - Guillaume Eberst
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
- University Hospital, Besançon, Department of Pneumology, Besancon, France
| | - Didier Ducloux
- University Hospital, Besançon, Department of Nephrology, Dialysis and Renal Transplantation, Besancon, France
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
| | - Céline Pursun
- University Hospital, Besançon, Department of Nephrology, Dialysis and Renal Transplantation, Besancon, France
| | - Marie Agnes Dragon Durey
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM UMRS 1138, Cordelier Research Center, Paris, France
- Université de Paris Cité, Paris, France
| | - Marie-Alexandra Alyanakia
- Service d’Immunologie Biologique, Hôpital Necker-Enfants Malades, Assistance Publique- Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France
| | - Sophie Felix
- University Hospital, Besançon, Department of Pathology, Besancon, France
| | - Thomas Crepin
- University Hospital, Besançon, Department of Nephrology, Dialysis and Renal Transplantation, Besancon, France
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
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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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IgA vasculitis as an immune-related adverse event of durvalumab: A case report. Respir Investig 2023; 61:205-209. [PMID: 36773508 DOI: 10.1016/j.resinv.2023.01.005] [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: 10/31/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 02/11/2023]
Abstract
A 78-year-old man with lung cancer underwent concurrent chemoradiotherapy followed by durvalumab for 24 cycles. After 6 months, he presented with anorexia and palpable purpura of the lower extremities, with increased proteinuria, hematuria, and elevated creatinine levels. Skin and kidney biopsies suggested a diagnosis of IgA vasculitis. No evidence of cancer progression was found; moreover, no infection or drug could be identified as the cause. Therefore, he was diagnosed with IgA vasculitis as an immune-related adverse event (irAE) caused by durvalumab. Because immune checkpoint inhibitors can cause vasculitis, clinicians should be cautious during their administration and after their discontinuation.
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Cutaneous vasculitis associated with molecular tergeted therapies: systematic review of the literature. Clin Rheumatol 2023; 42:339-357. [PMID: 36369405 DOI: 10.1007/s10067-022-06406-6] [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: 06/19/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022]
Abstract
Cutaneo us vasculitis (CV) has a broad spectrum of etiologies, and drugs are one of the main culprits. With the increasing use of targeted therapies in medicine, especially in rheumatology and oncology, the number of CV cases reported due to these drugs has increased. Therefore, the recognition and treatment of CV associated with targeted agents have become more and more important. In the literature, anti-TNFs (n = 73, 59.5%), secukinumab (n = 7, 6%), rituximab (n = 5, 4%), tocilizumab (n = 1, 0.8%), ustekinumab (n = 8, 6.5%), abatacept (n = 3, 2.4%), Janus kinase inhibitors (n = 3, 2.4%), alemtuzumab (n = 3, 2.4%), and immune checkpoint inhibitors (n = 20, 16%) have been reported as responsible agents. However, our knowledge of the pathogenetic mechanisms is fairly limited, and the standardized management is yet to be established. Furthermore, though it is uncommon, this complication may pose a safety issue. In this manuscript, we reviewed the literature on CV with or without systemic involvement related to targeted agents. We also proposed the pathogenetic mechanisms of these adverse events. Thus, we aimed to make it easier for clinicians to manage similar cases by reviewing the diagnosis and treatment processes.
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Nagaoka-Takatori A, Ishii M, Hayama K, Obinata D, Yamaguchi K, Takahashi S, Fujita H. A Case of IgA Vasculitis During Nivolumab Therapy for Renal Cell Carcinoma. Clin Cosmet Investig Dermatol 2021; 14:1885-1888. [PMID: 34992403 PMCID: PMC8713720 DOI: 10.2147/ccid.s343876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/01/2021] [Indexed: 11/23/2022]
Abstract
A 50-year-old Japanese woman presented with a 4-day history of multiple purpura on her extremities and myalgia. She had been receiving nivolumab therapy for stage IV renal cell carcinoma for 18 months. Nivolumab was temporarily discontinued due to liver dysfunction and resumed 3 months before. Biopsy specimen revealed leukocytoclastic vasculitis, and direct immunofluorescence showed deposition of IgA and C3 in the vessel walls of the upper dermis. Based on these findings, a diagnosis of IgA vasculitis was made. She was treated with 20 mg/day of oral prednisolone, which resulted in the complete disappearance of purpura and myalgia. Although the patient needed temporary cessation of nivolumab therapy, she experienced no recurrence of purpura or myalgia, and the dose of prednisolone was gradually tapered to 5 mg/day. Although nivolumab can lead to various immune-related adverse events, vasculitis is rare. To the best of our knowledge, this is the second case of IgA vasculitis during nivolumab therapy.
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Affiliation(s)
- Asami Nagaoka-Takatori
- Division of Cutaneous Science, Department of Dermatology, Nihon University School of Medicine, Tokyo, 173-8610, Japan
| | - Madoka Ishii
- Division of Cutaneous Science, Department of Dermatology, Nihon University School of Medicine, Tokyo, 173-8610, Japan
| | - Koremasa Hayama
- Division of Cutaneous Science, Department of Dermatology, Nihon University School of Medicine, Tokyo, 173-8610, Japan
| | - Daisuke Obinata
- Department of Urology, Nihon University School of Medicine, Tokyo, 173-8610, Japan
| | - Kenya Yamaguchi
- Department of Urology, Nihon University School of Medicine, Tokyo, 173-8610, Japan
| | - Satoru Takahashi
- Department of Urology, Nihon University School of Medicine, Tokyo, 173-8610, Japan
| | - Hideki Fujita
- Division of Cutaneous Science, Department of Dermatology, Nihon University School of Medicine, Tokyo, 173-8610, Japan
- Correspondence: Hideki Fujita Division of Cutaneous Science, Department of Dermatology, Nihon University School of Medicine, 30-1 Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, JapanTel +81-3-3972-8111 (ext. 2502)Fax +81-3-5995-9841 Email
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Taoka M, Ochi N, Mimura A, Ichiyama N, Nagasaki Y, Nakagawa N, Nakanishi H, Yamane H, Oshiro Y, Monobe Y, Takigawa N. IgA Vasculitis in a Lung Cancer Patient During Chemoradiotherapy. Ther Clin Risk Manag 2021; 17:571-575. [PMID: 34113114 PMCID: PMC8184282 DOI: 10.2147/tcrm.s308771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/20/2021] [Indexed: 01/07/2023] Open
Abstract
A 72-year-old man with locally advanced lung squamous cell carcinoma experienced red purpura on the lower legs and hematuria when the disease progressed during definitive chemoradiotherapy. He had renal dysfunction and proteinuria. Biopsy specimens of the skin lesion and kidney revealed immunoglobulin A vasculitis. Potential causes such as paraneoplastic syndrome and cancer treatment have been proposed. The administration of steroids rapidly improved the symptoms. The presentation of immunoglobulin A vasculitis is accompanied by malignancies. Clinicians should keep this syndrome in mind, even during curative-intent treatment.
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Affiliation(s)
- Masataka Taoka
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Nobuaki Ochi
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Ayaka Mimura
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Naruhiko Ichiyama
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Yasunari Nagasaki
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Nozomu Nakagawa
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Hidekazu Nakanishi
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Hiromichi Yamane
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Yoshiyuki Oshiro
- Department of General Internal Medicine 3, Kawasaki Medical School, Okayama, Japan
| | - Yasumasa Monobe
- Department of Pathology, Kawasaki Medical School, Okayama, Japan
| | - Nagio Takigawa
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
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