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Jeong J, Park S, Heo KN, Park SM, Min S, Ah YM, Han JM, Lee JY. Comprehensive analysis of nationwide anticancer drug-related complications in Korea: incidence, types, and cancer-specific considerations in contemporary oncology. Ther Adv Med Oncol 2024; 16:17588359241272970. [PMID: 39206378 PMCID: PMC11350537 DOI: 10.1177/17588359241272970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/17/2024] [Indexed: 09/04/2024] Open
Abstract
Background The rising global incidence of cancer has increased the demand for chemotherapy, which is a crucial treatment modality. Recent advancements in cancer treatment, including targeted agents and immunotherapy, have introduced complications owing to their specific mechanisms. However, comprehensive studies of the combined complications of these approaches are lacking. Objectives This study aimed to comprehensively assess and analyze the overall incidence of anticancer drug-related complications in a nationwide patient cohort, utilizing a customized National Health Insurance Sharing Service database in Korea. Design Retrospective cohort study. Methods We included patients who were prescribed anticancer drugs (excluding endocrine agents) and diagnosed with cancer. For the type of cancer classification, the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) was used and anticancer drugs were classified based on the Anatomical Therapeutic Chemical code. We classified cancer into 18 types based on the ICD-10 code and delineated cancer-related complications into 12 categories. Complications included hematological, gastrointestinal, infectious, cardiovascular, major bleeding, endocrine, neurotoxic, nephrotoxic, dermatological, pulmonary, musculoskeletal, and hepatotoxic effects. Result We included 294,544 patients diagnosed with cancer and administered anticancer drugs between 2016 and 2018, with follow-up continuing until 2021. We identified 486,929 anticancer drug-related complications, with an incidence of 1843.6 per 1000 person-years (PY). Anemia was the most common complication, with a rate of 763.7 per 1000 PY, followed by febrile neutropenia (295.7) and nausea/vomiting (246.9). Several complications peaked during the first months following the initiation of anticancer drug therapy; however, herpes, skin infection, heart failure, and peripheral neuropathy peaked at 6-12 months. Among major cancers, breast cancer had the lowest overall incidence of complications. Targeted therapies revealed lower complication rates than cytotoxic chemotherapy; however, they also required careful monitoring of rash. Conclusion This study highlights the importance of the proactive management of anticancer drug-related complications for patient care improvement.
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Affiliation(s)
- Jonghyun Jeong
- College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Soyoung Park
- College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Kyu-Nam Heo
- College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Soh Mee Park
- College of Pharmacy, Seoul National University, Seoul, Republic of Korea
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sangil Min
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsangbuk-do, Republic of Korea
| | - Ji Min Han
- College of Pharmacy, Chungbuk National University, 194-21 Osongsaengmyeong 1-ro, Osong-eup, Cheongju 28160, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1, Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
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Khan IR, Sadida HQ, Hashem S, Singh M, Macha MA, Al-Shabeeb Akil AS, Khurshid I, Bhat AA. Therapeutic implications of signaling pathways and tumor microenvironment interactions in esophageal cancer. Biomed Pharmacother 2024; 176:116873. [PMID: 38843587 DOI: 10.1016/j.biopha.2024.116873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/21/2024] [Accepted: 06/03/2024] [Indexed: 06/20/2024] Open
Abstract
Esophageal cancer (EC) is significantly influenced by the tumor microenvironment (TME) and altered signaling pathways. Downregulating these pathways in EC is essential for suppressing tumor development, preventing metastasis, and enhancing therapeutic outcomes. This approach can increase tumor sensitivity to treatments, enhance patient outcomes, and inhibit cancer cell proliferation and spread. The TME, comprising cellular and non-cellular elements surrounding the tumor, significantly influences EC's development, course, and treatment responsiveness. Understanding the complex relationships within the TME is crucial for developing successful EC treatments. Immunotherapy is a vital TME treatment for EC. However, the heterogeneity within the TME limits the application of anticancer drugs outside clinical settings. Therefore, identifying reliable microenvironmental biomarkers that can detect therapeutic responses before initiating therapy is crucial. Combining approaches focusing on EC signaling pathways with TME can enhance treatment outcomes. This integrated strategy aims to interfere with essential signaling pathways promoting cancer spread while disrupting factors encouraging tumor development. Unraveling aberrant signaling pathways and TME components can lead to more focused and efficient treatment approaches, identifying specific cellular targets for treatments. Targeting the TME and signaling pathways may reduce metastasis risk by interfering with mechanisms facilitating cancer cell invasion and dissemination. In conclusion, this integrative strategy has significant potential for improving patient outcomes and advancing EC research and therapy. This review discusses the altered signaling pathways and TME in EC, focusing on potential future therapeutics.
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Affiliation(s)
- Inamu Rashid Khan
- Department of Zoology, Central University of Kashmir, Ganderbal, Jammu and Kashmir 191201, India
| | - Hana Q Sadida
- Department of Human Genetics-Precision Medicine in Diabetes, Obesity and Cancer Program, Sidra Medicine, Doha 26999, Qatar
| | - Sheema Hashem
- Department of Human Genetics, Sidra Medicine Doha 26999, Qatar
| | - Mayank Singh
- Department of Medical Oncology (Lab), Dr. B. R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Muzafar A Macha
- Watson-Crick Centre for Molecular Medicine, Islamic University of Science and Technology, Awantipora, Jammu and Kashmir 192122, India
| | - Ammira S Al-Shabeeb Akil
- Department of Human Genetics-Precision Medicine in Diabetes, Obesity and Cancer Program, Sidra Medicine, Doha 26999, Qatar
| | - Ibraq Khurshid
- Department of Zoology, Central University of Kashmir, Ganderbal, Jammu and Kashmir 191201, India.
| | - Ajaz A Bhat
- Department of Human Genetics-Precision Medicine in Diabetes, Obesity and Cancer Program, Sidra Medicine, Doha 26999, Qatar.
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Pini F, Grigoriu B, Lieveke A, Meert AP. Management and outcome of oncological patients under immune checkpoint inhibitors presenting at the emergency department. Emerg Med J 2024; 41:417-421. [PMID: 38688713 DOI: 10.1136/emermed-2023-213605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION With the rising use of immune checkpoint inhibitors (ICIs) in oncology, emergency physicians are increasingly confronted with their immune-related adverse events (irAEs). We described the types of irAEs presenting to the ED of a Belgian cancer centre and determined associations with the development of an irAE and other patient's characteristics. Secondary objectives describe the therapeutic management and determine 7 and 30-day mortality. METHODS A retrospective chart review of ED visits of patients on ICI from 15 December 2016 to 6 December 2020 was performed. Clinical presentation, cancer characteristics and type of ICI were extracted by a single abstractor. We recorded any suspicion of irAE in the ED and confirmation of an irAE was based on the patient's oncologist report. Outcome was based on mortality at date of last follow-up. RESULTS 227 patients on ICI presented to the ED, with a total of 451 visits. 54 (12%) of the visits resulted in a diagnosis of irAE. Four clinical features were associated with an irAE: gastrointestinal complaints (p=0.01), skin rashes (p=0.02), acute renal failure (p=0.002) and abnormal liver function (p=0.04). An irAE was also associated with three different factors: a cancer status in remission (OR=5.33, 95% CI 2.57 to 11.04), a combination of two ICIs (OR=4.43, 95% CI 2.09 to 9.42) and a medical history of irAE (OR=2.44, 95% CI 1.27 to 4.68). 30-day mortality was lower in the irAE group (0%) than in the non-irAE group (13%, 95% CI 9% to 19%). CONCLUSIONS Oncological patients under ICI presenting in the ED are more likely to have an irAE if they present with gastrointestinal and dermatological complaints, acute renal failure and abnormal liver function. This is also true for patients with any history of irAE, a concomitant use of two ICIs and with a cancer status in remission.
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Del Gaudio A, Di Vincenzo F, Petito V, Giustiniani MC, Gasbarrini A, Scaldaferri F, Lopetuso LR. Focus on Immune Checkpoint Inhibitors-related Intestinal Inflammation: From Pathogenesis to Therapeutical Approach. Inflamm Bowel Dis 2024; 30:1018-1031. [PMID: 37801695 PMCID: PMC11144981 DOI: 10.1093/ibd/izad229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Indexed: 10/08/2023]
Abstract
Recently, antitumor immunotherapies have witnessed a breakthrough with the emergence of immune checkpoint inhibitors (ICIs) including programmed cell death-1 (PD-1), programmed cell death-ligand 1 (PD-L1), and cytotoxic T lymphocyte antigen 4 (CTLA-4) inhibitors. Unfortunately, the use of ICIs has also led to the advent of a novel class of adverse events that differ from those of classic chemotherapeutics and are more reminiscent of autoimmune diseases, the immune-related adverse events (IRAEs). Herein, we performed an insight of the main IRAEs associated with ICIs, focusing on gastroenterological IRAEs and specifically on checkpoint inhibitor colitis, which represents the most widely reported IRAE to date. We comprehensively dissected the current evidence regarding pathogenesis, diagnosis, and management of ICIs-induced colitis, touching upon also on innovative therapies.
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Affiliation(s)
- Angelo Del Gaudio
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Federica Di Vincenzo
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Valentina Petito
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | | | - Antonio Gasbarrini
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Franco Scaldaferri
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Loris Riccardo Lopetuso
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- Department of Medicine and Ageing Sciences, G. d’Annunzio University of Chieti-Pescara, Chieti, 66100, Italy
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, Chieti, 66100, Italy
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Benz S, Sherman KA, Dasanu CA, Alvarez-Argote J. Immune checkpoint inhibitor-related adverse events: Real-world experience from a single veterans' affairs medical center. J Oncol Pharm Pract 2024; 30:697-704. [PMID: 37350125 DOI: 10.1177/10781552231184178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are antineoplastic agents associated with a multitude of immune-related adverse events (irAEs). Available data from clinical trials include highly selective patient populations which may limit their applicability to real-world clinical practice. METHODS We present a retrospective cohort study of cancer patients treated with ICI therapy at the Zablocki VA Medical Center between 2014 and 2021. Information on demographics, cancer diagnosis, type of therapy, treatment duration, comorbidities, irAE type, and overall survival were collected. RESULTS We identified 187 patients who received at least one dose of ICI. About half the patients experienced at least one irAE, the most common categories being fatigue, pulmonary, and endocrine irAEs. Approximately half of the irAEs were diagnosed within the first three months of starting ICI therapy, and 60.38% of those who experienced irAEs discontinued ICI therapy. Patients who experienced endocrine or intestinal irAEs had a significantly longer overall survival. CONCLUSION Immune-related complications due to ICI therapy are common and can frequently lead to treatment discontinuation in the real-world setting. Endocrine and intestinal irAEs may correlate with improved survival. The ICI-treated patients who received palliative radiation therapy to the bone had less irAEs, possibly due to immunogenic cell death.
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Affiliation(s)
- Samantha Benz
- Department of Medicine, Zablocki Veterans Affairs Medical Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Katherine A Sherman
- Department of Research Health, Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
| | - Constantin A Dasanu
- Lucy Curci Cancer Center, Eisenhower Health, Rancho Mirage, CA, USA
- Department of Medical Oncology and Hematology, University of California in San Diego Health System, San Diego, CA, USA
| | - Juliana Alvarez-Argote
- Division of Hematology-Oncology, Department of Medicine, Zablocki Veterans Affairs Medical Center, Medical College of Wisconsin, Milwaukee, WI, USA
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6
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Yeung SCJ, Qdaisat A, Bischof JJ, Caterino JM, Kyriacou DN, Coyne Md C. A case series of adrenal insufficiency (likely due to hypophysitis) in cancer patients treated with immune checkpoint inhibitors. Am J Emerg Med 2024; 80:227.e1-227.e5. [PMID: 38705758 DOI: 10.1016/j.ajem.2024.04.046] [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: 12/05/2023] [Revised: 03/24/2024] [Accepted: 04/26/2024] [Indexed: 05/07/2024] Open
Abstract
The number of approved immune checkpoint inhibitors (ICIs) and their indications have significantly increased over the past decade. Immune-related adverse effects (irAEs) of ICIs vary widely in presentation and symptoms and can present diagnostic challenges to emergency department (ED) physicians. Moreover, when ICIs are combined with radiotherapy, cytotoxic chemotherapy, or targeted therapy, the attribution of signs and symptoms to an immune-related cause is even more difficult. Here, we report a series of 5 ED cases of adrenal insufficiency in ICI-treated cancer patients. All 5 patients presented with severe fatigue and nausea. Four patients definitely had and one patient possibly had central adrenal insufficiency, and 4 patients had undetectable serum cortisol levels. The majority of the patients had nonspecific symptoms that were not recognized at their first ED presentation. These cases illustrate the need for a heightened level of suspicion for adrenal insufficiency in ICI-treated cancer patients with hypotension, nausea and/or vomiting, abdominal pain, fatigue, or hypoglycemia. As ICI use increases, irAE-associated oncologic emergencies will become more prevalent. Thus, ED physicians must update their knowledge regarding the diagnosis and management of irAEs and routinely inquire about the specific antineoplastic therapies that their ED patients with cancer are receiving. A random cortisol level (results readily available in most EDs) with interpretation taking the circadian rhythm and the current level of physiological stress into consideration can inform the differential diagnosis and whether further investigation of this potential irAE is warranted.
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Affiliation(s)
- Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jason J Bischof
- Department of Emergency Medicine, Ohio State University, Columbus, OH, United States
| | - Jeffrey M Caterino
- Department of Emergency Medicine, Ohio State University, Columbus, OH, United States
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University, Chicago, IL, United States
| | - Christopher Coyne Md
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, United States
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Tomm NK, Szczepanski JM, Fang JM, Choi WT, Xue Y, Setia N, Karamchandani DM, Cheng JY, Westerhoff M. Follow-up biopsies in gastrointestinal immune checkpoint inhibitor toxicity may show markedly different inflammatory patterns than initial injury. Hum Pathol 2024; 148:60-65. [PMID: 38734079 DOI: 10.1016/j.humpath.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024]
Abstract
Colitis is a common manifestation of immune checkpoint inhibitor (ICI) toxicity and can present with varied histologic patterns of inflammation, some of which have been shown to be associated with specific ICI drug types. Although the histologic features of ICI colitis seen at the time of diagnosis have been described, there have been few reports following these patients over time. We evaluated initial and follow-up biopsies in 30 patients with ICI colitis and found that 37% of patients developed a different pattern of injury on follow-up biopsy compared to the initial biopsy. Patients with a different inflammatory pattern were more likely to have restarted ICI therapy before their follow-up biopsy (64%) compared to those without a change in inflammatory pattern (11%; P < 0.01). The majority of these patients had changed ICI drug types (86%). Additionally, many cases changed to an inflammatory bowel disease (IBD)-like pattern (36%), raising a question of de novo IBD. However, all of our patients with an IBD-like pattern experienced sustained resolution of symptoms without steroids or other immunosuppressive medications following discontinuation of ICI therapy, consistent with a diagnosis of ICI toxicity. Our findings suggest that follow-up biopsies in patients with ICI colitis may show a different histology and that this does not necessarily warrant a change in the histologic diagnosis to another disease.
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Affiliation(s)
- Nicole K Tomm
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA.
| | - Julianne M Szczepanski
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA
| | - Jiayun M Fang
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA
| | - Won-Tak Choi
- Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, Suite M590, Box 0511, San Francisco, CA, 94143, USA
| | - Yue Xue
- Department of Pathology, Northwestern University Feinberg School of Medicine, 303 E. Chicago Ave., Ward 3-140, Chicago, IL, 60611, USA
| | - Namrata Setia
- Department of Pathology, University of Chicago, 5841 S. Maryland Ave., MC3083 - Rm. S329, Chicago, IL, 60637, USA
| | - Dipti M Karamchandani
- Department of Pathology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Jerome Y Cheng
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA
| | - Maria Westerhoff
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA
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Chen YH, Kovács T, Ferdinandy P, Varga ZV. Treatment options for immune-related adverse events associated with immune checkpoint inhibitors. Br J Pharmacol 2024. [PMID: 38803135 DOI: 10.1111/bph.16405] [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: 12/01/2023] [Revised: 02/14/2024] [Accepted: 03/09/2024] [Indexed: 05/29/2024] Open
Abstract
The immunotherapy revolution with the use of immune checkpoint inhibitors (ICIs) started with the clinical use of the first ICI, ipilimumab, in 2011. Since then, the field of ICI therapy has rapidly expanded - with the FDA approval of 10 different ICI drugs so far and their incorporation into the therapeutic regimens of a range of malignancies. While ICIs have shown high anti-cancer efficacy, they also have characteristic side effects, termed immune-related adverse events (irAEs). These side effects hinder the therapeutic potential of ICIs and, therefore, finding ways to prevent and treat them is of paramount importance. The current protocols to manage irAEs follow an empirical route of steroid administration and, in more severe cases, ICI withdrawal. However, this approach is not optimal in many cases, as there are often steroid-refractory irAEs, and there is a potential for corticosteroid use to promote tumour progression. This review surveys the current alternative approaches to the treatments for irAEs, with the goal of summarizing and highlighting the best attempts to treat irAEs, without compromising anti-tumour immunity and allowing for rechallenge with ICIs after resolution of the irAEs.
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Affiliation(s)
- Yu Hua Chen
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Tamás Kovács
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Zoltán V Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
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Okamoto K, Saito Y, Yamaguchi A, Takekuma Y, Sugawara M. Acid suppressants reduce the therapeutic effect of immune checkpoint inhibitors and increase the risk of acute kidney injury: a meta-analysis. Int J Clin Oncol 2023; 28:1343-1353. [PMID: 37421477 DOI: 10.1007/s10147-023-02385-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 07/03/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are used in cancer immunotherapy; however, they can lead to immune-related adverse events (irAEs) through immune function of patients. Therefore, this meta-analysis aimed to assess the concomitant effect of acid suppressants (ASs) on ICIs, including several subgroup analyses. METHODS We identified related studies and generated the forest plot. The primary endpoint was defined as the change in progression free survival (PFS) and overall survival (OS) with or without ASs administration. We also evaluated the effect of ASs on the incidence of irAEs. RESULTS The total hazard ratio (HR) of ASs on PFS with ICI treatment was 1.39 and the 95% confidence interval (95% CI) was 1.21-1.59 (Z: p < 0.00001). Moreover, the total HR of ASs on OS was 1.40 and the 95% CI was 1.21-1.61 (Z: p < 0.00001), suggesting that ASs reduced ICI's therapeutic effect. The total odds ratio (OR) for evaluating the effect of ASs on irAEs was 1.23 with a 95% CI of 0.81-1.88 (Z: p = 0.34). However, ASs significantly worsened acute kidney injury (AKI) (total OR 2.10; 95% CI 1.74-2.53 (Z, p < 0.00001)). Furthermore, although proton pump inhibitors (PPIs) reduced ICI's therapeutic effect, histamine H2-receptor antagonists (H2RAs) did not affect OS. CONCLUSIONS It was shown that ASs, especially PPIs, reduced ICI's therapeutic effect, while H2RAs had no effect, and ASs did not affect irAEs; however, it is a risk factor for ICIs-induced AKI.
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Affiliation(s)
- Keisuke Okamoto
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan
| | - Yoshitaka Saito
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan
| | - Atsushi Yamaguchi
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan
- Laboratory of Clinical Pharmaceutics and Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan
| | - Yoh Takekuma
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan
| | - Mitsuru Sugawara
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan.
- Laboratory of Pharmacokinetics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan.
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10
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Evaluation and management of acute high-grade immunotherapy-related neurotoxicity. Heliyon 2023; 9:e13725. [PMID: 36851967 PMCID: PMC9958505 DOI: 10.1016/j.heliyon.2023.e13725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Immune checkpoint inhibitor monoclonal antibodies allow the host's immune system to attack tumors, which has revolutionized cancer care over the last decade. As the use of immune checkpoint inhibitors has expanded, so have autoimmune-like complications known as immune-related adverse events. These include the infrequent but increasingly more common, potentially deadly neurological immune related adverse events. When feeling acutely ill, patients will often seek care not from their oncologist but from their family physician, clinics, emergency, and urgent care sites, or other available providers. Thus, while assessing acutely ill cancer patients who are experiencing neurological symptoms, non-oncologists should be prepared to recognize, diagnose, and treat neurological immune related adverse events in addition to more familiar conditions. This narrative review is designed to update acute care clinicians on current knowledge and to present a symptom-based framework for evaluating and treating neurological immune related adverse events based on the leading immunotoxicity organizations' latest recommendations.
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Liu H, Luo SX, Jie J, Peng L, Wang S, Song L. Immune checkpoint inhibitors related respiratory disorders in patients with lung cancer: A meta-analysis of randomized controlled trials. Front Immunol 2023; 14:1115305. [PMID: 36926326 PMCID: PMC10011157 DOI: 10.3389/fimmu.2023.1115305] [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: 12/03/2022] [Accepted: 02/14/2023] [Indexed: 03/08/2023] Open
Abstract
Background In recent years, immune checkpoint inhibitors (ICIs) had extremely rapid growth in anti-cancer and improved outcomes of many malignancies, specifically lung cancer. However, the incidence of ICIs-related adverse events also raised. Using this meta-analysis, ICIs-related respiratory disorders were investigated in lung cancer patients. Methods Using Cochrane Library, Embase, and PubMed databases, we performed an integrated search for randomized controlled trials (RCTs) to compare respiratory disorders among different regimens. The data was prepared with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, and the quality of included studies was evaluated based on the Cochrane manual. Results In total, 22 RCTs were involved in this meta-analysis. Compared with ICIs, chemotherapy reduced the risk of interstitial lung disease (p = 0.03; SMD: 2.81; 95% CI: 1.08, 7.27), pleural effusion (p = 0.002; SMD: 2.12; 95% CI: 1.32, 3.42), and pneumonitis (p < 0.00001; SMD: 9.23; 95% CI: 4.57, 18.64). ICIs plus chemotherapy could provide a higher probability for patients to suffer pneumonitis than chemotherapy (p = 0.01; SMD: 1.96; 95% CI: 1.17, 3.28). In addition, single ICI brought a lower likelihood for patients suffering pneumonitis than double ICIs (p = 0.004; SMD: 2.17; 95% CI: 1.27, 3.69). Conclusion ICIs-based treatment, such as ICIs alone, ICIs plus chemotherapy and double ICIs, can raise the incidences of some respiratory disorders in patients with lung cancer. It suggests that ICIs should be conducted based on a comprehensive consideration to prevent ICIs-related respiratory disorders. To a certain degree, this study might be provided to the clinician as a reference for ICIs practice. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022378901, identifier (CRD42022378901).
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Affiliation(s)
- Han Liu
- Department of Respiratory Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Sean X Luo
- Department of Vascular Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jing Jie
- Department of Respiratory Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Liping Peng
- Department of Respiratory Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Shuai Wang
- Department of Vascular Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Lei Song
- Department of Respiratory Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
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12
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Sener U, Ruff MW, Campian JL. Immunotherapy in Glioblastoma: Current Approaches and Future Perspectives. Int J Mol Sci 2022; 23:7046. [PMID: 35806051 PMCID: PMC9266573 DOI: 10.3390/ijms23137046] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/16/2022] [Accepted: 06/22/2022] [Indexed: 02/04/2023] Open
Abstract
Glioblastoma (GBM) is the most common malignant brain tumor. Despite multimodality treatment with surgical resection, radiation therapy, chemotherapy, and tumor treating fields, recurrence is universal, median observed survival is low at 8 months and 5-year overall survival is poor at 7%. Immunotherapy aims to generate a tumor-specific immune response to selectively eliminate tumor cells. In treatment of GBM, immunotherapy approaches including use of checkpoint inhibitors, chimeric antigen receptor (CAR) T-Cell therapy, vaccine-based approaches, viral vector therapies, and cytokine-based treatment has been studied. While there have been no major breakthroughs to date and broad implementation of immunotherapy for GBM remains elusive, multiple studies are underway. In this review, we discuss immunotherapy approaches to GBM with an emphasis on molecularly informed approaches.
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Affiliation(s)
- Ugur Sener
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Michael W. Ruff
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Jian L. Campian
- Department of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA;
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13
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Moschen AR, Sammy Y, Marjenberg Z, Heptinstall AB, Pooley N, Marczewska AM. The Underestimated and Overlooked Burden of Diarrhea and Constipation in Cancer Patients. Curr Oncol Rep 2022; 24:861-874. [PMID: 35325401 DOI: 10.1007/s11912-022-01267-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize and discuss the diverse causes of two major gastrointestinal dysfunction symptoms, diarrhea and constipation, in cancer patients. We also discuss short- and long-term clinical, economic, and humanistic consequences, including the impact on cancer treatment regimens and patient quality of life, highlighting the limitations of the literature. RECENT FINDINGS Diarrhea and constipation as a result of cancer and its treatment can risk the success of anti-cancer therapies by requiring treatment delay or withdrawal, and imposes a substantial humanistic burden in patients with cancer. Despite its importance and frequency, gastrointestinal side effects may be overlooked due to the focus on cancer treatment, and the impact on patients may be underestimated. Additionally, the burden reported may not fully reflect current cancer management, particularly the true impact of economic consequences. A full understanding of the burden of diarrhea and constipation in patients with cancer is required, including broad evaluation of clinical considerations, the patient experience, and an updated assessment of economic burden. This would improve caregivers' appreciation of the impact of gastrointestinal dysfunction and aid the prioritization of future research efforts.
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Castillo RM, Sandefur BJ, Finch AS, Richter MD, Thanarajasingam U. Clinical Presentations and Outcomes of Patients Receiving Immune Checkpoint Inhibitors Presenting to the Emergency Department. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1029-1035. [PMID: 34765885 PMCID: PMC8569628 DOI: 10.1016/j.mayocpiqo.2021.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are increasingly used in the treatment of cancer. Immune checkpoint inhibitors may cause a wide-range of autoimmune toxicities referred to as immune-related adverse events (irAEs). There is a paucity of data regarding the presentations and outcomes of patients receiving ICIs who seek care in an emergency department (ED). We performed a retrospective review of patients receiving an ICI who presented to a tertiary care ED between May 1, 2017, and April 30, 2018. Data including ED chief complaint, diagnosis, treatment, and disposition were collected along with baseline characteristics and diagnosis at the time of outpatient oncology follow-up. We report descriptive statistics summarizing the characteristics of the cohort. There were 98 ED visits identified among 67 unique patients. Immune-related adverse events were diagnosed in 16 (16.3%) cases. The most common chief complaints within the irAE group were gastrointestinal symptoms 10 (62.5%). Among the 16 confirmed irAE cases, the most common irAE diagnosed was colitis 9 (56.3%). Two (12.5%) patients with irAEs received corticosteroids during their stay in the ED, and 10 (62.5%) patients with irAEs required hospital admission. Emergency medicine providers documented consideration of an irAE in the differential diagnosis in 14.3% of all ED visits and in 43.8% of visits in which an irAE was ultimately diagnosed. Emergency providers should be familiar with ICIs given their expanding use and potential adverse effects to improve early recognition and patient outcomes in ED settings.
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Affiliation(s)
- Richmond M. Castillo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | - Uma Thanarajasingam
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN
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15
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de Vries F, van Furth WR, Biermasz NR, Pereira AM. Hypophysitis: A comprehensive overview. Presse Med 2021; 50:104076. [PMID: 34687912 DOI: 10.1016/j.lpm.2021.104076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Hypophysitis is defined as inflammation of the pituitary gland. It is a heterogeneous condition as it can originate from different parts of the pituitary gland, can be caused by different pathophysiological processes, and can be isolated or the manifestation of a underlying systemic disease. Hypophysitis usually presents with endocrine deficiencies, including diabetes insipidus, with varying patterns. A subset of patients presents with mass effects. The last decades major progress has been made in the understanding of this disease. New forms are now recognized, new diagnostics are being developed, and specific treatments are proposed. This review provides an overview of the current knowledge on hypophysitis using an aetiology-based approach and provides the clinician with a stepwise approach to the patient with (suspected) hypophysitis.
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Affiliation(s)
- F de Vries
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
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Imaging of Cancer Immunotherapy: Response Assessment Methods, Atypical Response Patterns, and Immune-Related Adverse Events, From the AJR Special Series on Imaging of Inflammation. AJR Am J Roentgenol 2021; 218:940-952. [PMID: 34612682 DOI: 10.2214/ajr.21.26538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The introduction of immunotherapy with immune-checkpoint inhibitors (ICIs) has revolutionized cancer treatment paradigms. Since the FDA approval of the first ICI in 2011, multiple additional ICIs have been approved and granted marketing authorization, and many promising agents are in early clinical adoption. Due to the distinctive biologic mechanisms of ICIs, the patterns of tumor response and progression differ for immunotherapy from those observed with cytotoxic chemotherapies. With increasing clinical adoption of immunotherapy, it is critical for radiologists to recognize different response patterns and common pitfalls to avoid misinterpretation of imaging studies or prompt premature cessation of potentially effective treatment. This article provides an overview of ICIs and their mechanisms of action and reviews the anatomic and metabolic immune-related response assessment methods, typical and atypical patterns of immunotherapy response (including pseudoprogression, hyper-progression, dissociated response, and durable response), and common imaging features of immune-related adverse events. Future multicenter trials are needed to validate the proposed immune-related response criteria and identify the functional imaging markers of early treatment response and survival.
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17
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Immune checkpoint inhibitors: An emergency medicine focused review. Am J Emerg Med 2021; 50:335-344. [PMID: 34450397 DOI: 10.1016/j.ajem.2021.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/16/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Several novel cancer therapies have been developed, many of which focused on immune system modulation. These include immune checkpoint inhibitors, modulators, T-cell therapy, monoclonal antibodies, cytokines, oncolytic viruses, and vaccines. Although many of these therapies are well tolerated, significant adverse reactions can occur as a result of these novel drugs. OBJECTIVE This narrative review discusses complications associated with immune based cancer therapies, specifically immune checkpoint inhibitors, for emergency clinicians. DISCUSSION Novel cancer therapies including immune checkpoint inhibitors can improve the care of patients with malignancy. However, these therapies have a number of potential complications, known as immune-related adverse events (irAEs). Complications can involve the neurologic, cardiac, pulmonary, dermatologic, renal, gastrointestinal, hepatic, and hematologic systems. IrAEs most commonly occur in the first several months following treatment initiation. These complications can be graded based on severity of clinical and laboratory findings. While most of these irAEs are mild, patients may present with critical illness. Treatment commonly includes immune checkpoint inhibitor discontinuation, steroids, and evaluation for other immunosuppressant medications. CONCLUSIONS Knowledge of this novel cancer therapy class and its potential complications can improve the care of patients on immune checkpoint inhibitors in the emergency department setting.
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Cardiotoxicity associated with immune checkpoint inhibitors and CAR T-cell therapy. Am J Emerg Med 2021; 50:51-58. [PMID: 34274878 DOI: 10.1016/j.ajem.2021.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The expanding use of immunotherapy and the growing population of patients with cancer has led to an increase in the reporting of immune related adverse events (irAEs). The emergency clinician should be aware of these emerging toxicities, some of which can be fatal. In this review we discuss the cardiotoxic side effects of immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T-cell (CAR T-cell) therapy. DISCUSSION Recognizing the possible presentations of cardiotoxic irAEs is of utmost important as the diagnosis of cardiotoxicity associated with ICI and CAR T-cell can be difficult to make in the emergency department. The emergency clinician will have to presume the diagnosis and treat it without final confirmation in most cases. For this reason, if the diagnosis is suspected, early involvement of the cardiologist and oncologist is important to help guide management. Most irAEs will be treated with glucocorticoids, but in the case of CAR T-cell cardiotoxicity, Tocilizumab should be used as first line. CONCLUSION Although cardiotoxicity is rare, it is often life-threatening. Treatment should be initiated as soon as the diagnosis is suspected, and early involvement of the cardiologist and oncologist is imperative for optimal treatment.
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19
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Kamyshova ES, Bobkova IN, Sekacheva MI. Kidney injury associated with antitumor therapy: focus on the adverse events of modern immuno-oncological drugs. TERAPEVT ARKH 2021; 93:649-660. [DOI: 10.26442/00403660.2021.06.200860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022]
Abstract
Immune checkpoint inhibitors (ICIs), including cytotoxic T-lymphocyte associated antigen 4 (CTLA-4) and programmed death protein 1 (PD-1) or its ligand (PD-L1), are a new generation of immuno-oncological drugs that to date have demonstrated efficacy in a number of malignancies. The mechanism of ICT inhibitors action consist in the potentiation of the immune response by eliminating the tumor cells inhibitory effect on the T-lymphocytes activation. However, excessive immune system activation can cause the development of a special class of immune-related adverse events (irAEs) involved a wide variety of organs and systems, including the kidneys. Despite the fact that immuno-mediated kidney injury caused by ICI therapy develops quite rarely, it can be serious and determine the patient's prognosis, which necessitates early diagnosis and timely start of treatment. In this regard, awareness of the manifestations of ICI-associated renal irAEs is particularly relevant not only for oncologists and for nephrologists, but for doctors of other specialties. In this review, we elucidated the main variants of immuno-mediated kidney injury caused by ICI therapy, discussed possible predictors and mechanisms of their development, and considers the general principles of diagnosis and management of patients according to the severity of irAEs.
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20
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Green HE, Nieva J. Clinical management of immune-related adverse events following immunotherapy treatment in patients with non-small cell lung cancer. J Investig Med 2021; 69:1281-1286. [PMID: 34127515 PMCID: PMC8478790 DOI: 10.1136/jim-2021-001806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/04/2022]
Abstract
The advent of checkpoint blockade-based immunotherapy is rapidly changing the management of lung cancer. Whereas past anticancer drugs' primary toxicity was hematologic, the newer agents have primarily autoimmune toxicity. Thus, it is no longer enough for oncology practitioners to be skilled only in hematology. They must also understand management of autoimmune conditions, leveraging the skills of the rheumatologist, endocrinologist and gastroenterologist in the process. Herein we describe the mechanism of action and toxicities associated with immune checkpoint blockade in patients with lung cancer and provide a framework for management of adverse events.
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Affiliation(s)
| | - Jorge Nieva
- Department of Internal Medicine, Division of Medical Oncology, University of Southern California - Norris Comprehensive Cancer Center and Hospital, Los Angeles, California, USA
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21
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Chhabra N, Kennedy J. A Review of Cancer Immunotherapy Toxicity: Immune Checkpoint Inhibitors. J Med Toxicol 2021; 17:411-424. [PMID: 33826117 DOI: 10.1007/s13181-021-00833-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 02/07/2023] Open
Abstract
Cancer immunotherapy, which leverages features of the immune system to target neoplastic cells, has revolutionized the treatment of cancer. The use of these therapies has rapidly expanded in the past two decades. Immune checkpoint inhibitors represent one drug class within immunotherapy with its first agent FDA-approved in 2011. Immune checkpoint inhibitors act by disrupting inhibitory signals from neoplastic cells to immune effector cells, allowing activated T-cells to target these neoplastic cells. Unique adverse effects associated with immune checkpoint inhibitors are termed immune-related adverse effects (irAEs) and are usually immunostimulatory in nature. Almost all organ systems may be affected by irAEs including the dermatologic, gastrointestinal, pulmonary, endocrine, and cardiovascular systems. These effects range from mild to life-threatening, and their onset can be delayed several weeks or months. For mild irAEs, symptomatic care is usually sufficient. For higher grade irAEs, discontinuation of therapy and initiation of immunosuppressive therapy may be necessary. The management of patients with irAEs involves multidisciplinary care coordination with respect to the long-term goals the individual patient. Clinicians must be aware of the unique and sometimes fatal toxicologic profiles associated with immunotherapies to ensure prompt diagnosis and appropriate management.
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Affiliation(s)
- Neeraj Chhabra
- Cook County Health, Department of Emergency Medicine, Division of Medical Toxicology, 1950 W Polk Street, 7th Floor, Chicago, IL, 60612, USA. .,Toxikon Consortium, Chicago, IL, USA.
| | - Joseph Kennedy
- Cook County Health, Department of Emergency Medicine, Division of Medical Toxicology, 1950 W Polk Street, 7th Floor, Chicago, IL, 60612, USA.,Toxikon Consortium, Chicago, IL, USA
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22
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Emergency Presentations of Immune Checkpoint Inhibitor-Related Endocrinopathies. J Emerg Med 2021; 61:140-146. [PMID: 33795170 DOI: 10.1016/j.jemermed.2021.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/07/2021] [Accepted: 02/06/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) are an important component of anticancer treatment, with indications across an increasing range of oncological diagnoses. ICIs are associated with a range of immune-mediated toxicities. Immune-related endocrinopathies pose a distinct challenge, given the nonspecific symptom profile and potentially life-threatening sequelae if not recognized. OBJECTIVES To determine the frequency and clinical presentations of immune-mediated endocrinopathies in patients treated with ICIs presenting as emergencies. METHODS A prospective observational cohort study was undertaken at a specialist oncology hospital in North West England from May 20, 2018 to May 19, 2020. Within the hospital, the Oncology Assessment Unit (OAU) acts as the receiving unit in which assessments are undertaken of all emergency presentations. All patients treated with ICIs presenting to the OAU were included. The primary outcome was diagnosis of an immune-mediated endocrinopathy. Length of inpatient stay, and 7- and 30-day mortality rates were examined. RESULTS During the study period, 684 patients treated with ICIs presented to the OAU. Twenty-four (3.5%) patients had an acute immune-mediated endocrinopathy, of which 17 had hypophysitis, 4 diabetes mellitus, 2 thyrotoxicosis, and 1 adrenalitis. Median length of stay for patients with hypophysitis was 1 day. No patient with an immune-mediated endocrinopathy died within 30 days of presentation. CONCLUSIONS Presentations to emergency settings with acute immune-mediated endocrinopathies are rare. Early recognition of immune-mediated toxicities is important, and particularly pertinent in ICI-related endocrinopathies, where even in life-threatening cases, the presentation can be vague and nonspecific.
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Gillis A, Ben Yaacov A, Agur Z. A New Method for Optimizing Sepsis Therapy by Nivolumab and Meropenem Combination: Importance of Early Intervention and CTL Reinvigoration Rate as a Response Marker. Front Immunol 2021; 12:616881. [PMID: 33732241 PMCID: PMC7959825 DOI: 10.3389/fimmu.2021.616881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/05/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Recently, there has been a growing interest in applying immune checkpoint blockers (ICBs), so far used to treat cancer, to patients with bacterial sepsis. We aimed to develop a method for predicting the personal benefit of potential treatments for sepsis, and to apply it to therapy by meropenem, an antibiotic drug, and nivolumab, a programmed cell death-1 (PD-1) pathway inhibitor. Methods: We defined an optimization problem as a concise framework of treatment aims and formulated a fitness function for grading sepsis treatments according to their success in accomplishing the pre-defined aims. We developed a mathematical model for the interactions between the pathogen, the cellular immune system and the drugs, whose simulations under diverse combined meropenem and nivolumab schedules, and calculation of the fitness function for each schedule served to plot the fitness landscapes for each set of treatments and personal patient parameters. Results: Results show that treatment by meropenem and nivolumab has maximum benefit if the interval between the onset of the two drugs does not exceed a dose-dependent threshold, beyond which the benefit drops sharply. However, a second nivolumab application, within 7–10 days after the first, can extinguish a pathogen which the first nivolumab application failed to remove. The utility of increasing nivolumab total dose above 6 mg/kg is contingent on the patient's personal immune attributes, notably, the reinvigoration rate of exhausted CTLs and the overall suppression rates of functional CTLs. A baseline pathogen load, higher than 5,000 CFU/μL, precludes successful nivolumab and meropenem combination therapy, whereas when the initial load is lower than 3,000 CFU/μL, meropenem monotherapy suffices for removing the pathogen. Discussion: Our study shows that early administration of nivolumab, 6 mg/kg, in combination with antibiotics, can alleviate bacterial sepsis in cases where antibiotics alone are insufficient and the initial pathogen load is not too high. The study pinpoints the role of precision medicine in sepsis, suggesting that personalized therapy by ICBs can improve pathogen elimination and dampen immunosuppression. Our results highlight the importance in using reliable markers for classifying patients according to their predicted response and provides a valuable tool in personalizing the drug regimens for patients with sepsis.
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Affiliation(s)
- Avi Gillis
- Institute for Medical Biomathematics (IMBM), Bene Ataroth, Israel
| | - Anat Ben Yaacov
- Institute for Medical Biomathematics (IMBM), Bene Ataroth, Israel
| | - Zvia Agur
- Institute for Medical Biomathematics (IMBM), Bene Ataroth, Israel
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Expected and non-expected immune-related adverse events detectable by CT. Eur J Radiol 2021; 138:109617. [PMID: 33676358 DOI: 10.1016/j.ejrad.2021.109617] [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: 11/18/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE Cancer treatments with immune checkpoint inhibitors (ICI) are associated with a unique set of drug toxicities called immune-related adverse events (irAES). The aim of the present study was to describe the radiological manifestation of irAES detectable by CT. METHOD Retrospective analysis of 284 patients treated with ICI for various types of advanced cancer; of them, 129 patients were selected, all having been treated with single-agent ICI, and all with a baseline CT scan and follow-up scans available at our Institute. CT examinations were reviewed by two radiologists involved in the study with a consensus reading. Imaging findings consistent with irAES were reported and correlated with clinical-laboratory data. RESULTS Immune-related adverse events were found in 25/129 (19.4 %) patients. No statistically significant differences were found in either the prevalence of irAES or in the time of onset of tumour type. Thoracic complications were detected in 14/25 (56.0 %) patients consisting in: 3 radiation recall pneumonia, 3 Transient Asymptomatic Pulmonary Opacities (TAPOs), 3 hypersensitivity pneumonia, 2 diffuse alveolar damage, 2 organizing pneumonia, 1 sarcoid-like reaction. In the remaining 11/25 (44.0 %), there were extra-pulmonary complications: 3 colitis, 4 cholecystitis, 2 pancreatitis and 2 cases of visceral ischemia. CONCLUSIONS Radiologists should be aware of the wide spectrum of irAES as they could affect the outcome. Pneumonia is the most frequent irAES; however, the international classification for interstitial lung disease does not seem to be capable of describing all possible drug-related pulmonary toxicities. Additional findings included TAPOs, radiation recall pneumonia and sarcoid-like reaction.
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Mao C, Zeng X, Zhang C, Yang Y, Xiao X, Luan S, Zhang Y, Yuan Y. Mechanisms of Pharmaceutical Therapy and Drug Resistance in Esophageal Cancer. Front Cell Dev Biol 2021; 9:612451. [PMID: 33644048 PMCID: PMC7905099 DOI: 10.3389/fcell.2021.612451] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/04/2021] [Indexed: 02/05/2023] Open
Abstract
Pharmaceutical therapies are essential for esophageal cancer (EC). For the advanced EC, the neoadjuvant therapy regimen, including chemotherapy plus radiotherapy and/or immunotherapy, is effective to achieve clinical benefit, even pathological complete response. For the unresectable, recurrent, and metastatic EC, the pharmaceutical therapy is the limited effective regimen to alleviate the disease and prolong the progression-free survival and overall survival. In this review, we focus on the pharmaceutical applications in EC treatment including cytotoxic agents, molecular targeted antibodies, and immune checkpoint inhibitors (ICIs). The chemotherapy regimen is based on cytotoxic agents such as platinum-based complexes, fluorinated pyrimidines and taxenes. Although the cytotoxic agents have been developed in past decades, the standard chemotherapy regimen is still the cisplatin and 5-FU or paclitaxel because the derived drugs have no significant advantages of overcoming the shortcomings of side effects and drug resistance. The targeted molecular therapy is an essential supplement for chemotherapy; however, there are only a few targeted therapies available in clinical practice. Trastuzumab and ramucirumab are the only two molecular therapy drugs which are approved by the US Food and Drug Administration to treat advanced and/or metastatic EC. Although the targeted therapy usually achieves effective benefits in the early stage therapy of EC, the patients will always develop drug resistance during treatment. ICIs have had a significant impact on routine clinical practice in cancer treatment. The anti-programmed cell death-1 monoclonal antibodies pembrolizumab and nivolumab, as the ICIs, are recommended for advanced EC by several clinical trials. However, the significant issues of pharmaceutical treatment are still the dose-limiting side effects and primary or secondary drug resistance. These defects of pharmaceutical therapy restrain the clinical application and diminish the effectiveness of treatment.
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Affiliation(s)
- Chengyi Mao
- Department of Thoracic Surgery West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoxi Zeng
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Chao Zhang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yushang Yang
- Department of Thoracic Surgery West China Hospital, Sichuan University, Chengdu, China
| | - Xin Xiao
- Department of Thoracic Surgery West China Hospital, Sichuan University, Chengdu, China
| | - Siyuan Luan
- Department of Thoracic Surgery West China Hospital, Sichuan University, Chengdu, China
| | - Yonggang Zhang
- Department of Periodical Press, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Yuan
- Department of Thoracic Surgery West China Hospital, Sichuan University, Chengdu, China
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Malignant Melanoma of the Gastrointestinal Tract: Symptoms, Diagnosis, and Current Treatment Options. Cells 2021; 10:cells10020327. [PMID: 33562484 PMCID: PMC7915313 DOI: 10.3390/cells10020327] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 12/21/2022] Open
Abstract
Malignant melanoma (MM) has become the fifth most frequent cancer in the UK. It is the most common carcinoma to metastasize to the gastrointestinal (GI) tract. MM particularly has an affinity to spread to the small bowel, which is followed by the involvement of the stomach and large intestine. Excellent endoscopic options including video capsule endoscopy and enteroscopy are available for a precise diagnosis of GI involvement by a metastatic MM. The complete surgical resection of GI metastatic MM in carefully selected patients not only provides symptom control, but has also been associated with an increase in overall survival. The approval of BRAF-targeted therapies and immune checkpoint inhibitors has transformed therapeutic approaches for patients with metastatic MM over the past decade. Currently, the overall survival of patients with advanced metastatic MM who have been treated with a combination of immunotherapeutic agents reaches 52% at five years. The role of surgery for patients with the metastatic involvement of the GI tract with MM is evolving in the era of effective systemic treatments.
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27
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Worku DA, Hewitt V. The role and economics of immunotherapy in solid tumour management. J Oncol Pharm Pract 2020; 26:2020-2024. [PMID: 33036547 PMCID: PMC7720357 DOI: 10.1177/1078155220963190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 11/17/2022]
Abstract
Cancer therapeutics is a rapidly changing field which offers patients the prospect of a better quality of life and cure. Immunotherapy has become a unique approach for select metastatic solid tumours. While initial results do show durable responses in select patients, there are concerns on how best to utilise this expensive resource which can result in costly side effects and in whom the use of biomarkers to stratify patients is still in its infancy. Given the ageing population and extreme challenges on healthcare, economic modelling with regards to immunotherapy is imperative especially now when it is being considered for further cancer types.
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Affiliation(s)
- Dominic Adam Worku
- Faculty of Medical Sciences, Oncology and Palliative Care Team, Newcastle University, Newcastle upon Tyne, UK
- St Georges Hospital, London, UK
| | - Victoria Hewitt
- Graduate School, Faculty Medical Sciences, Newcastle University, UK
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28
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Yeung SJ, Qdaisat A, Chaftari P, Lipe D, Merlin J, Rajha E, Wechsler A, Sandoval M, Viets J, Al‐Breiki A, Shah M, Pandey R, Kamal M, Khattab O, Toale K, Wattana M, Elsayem A, Gaeta S, Brock P, Reyes‐Gibby C, Alagappan K. Diagnosis and management of immune-related adverse effects of immune checkpoint therapy in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1637-1659. [PMID: 33392573 PMCID: PMC7771833 DOI: 10.1002/emp2.12209] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022] Open
Abstract
Rapid advances in cancer immunotherapy using immune checkpoint inhibitors have led to significantly improved survival. Rapid identification of the toxicity syndromes associated with these therapeutic agents is very important for emergency physicians because the population of patients diagnosed with cancer is increasing and cancer therapies including immune checkpoint inhibitors have become the first-line treatment for more and more types of cancer. The emergency medicine literature lags behind rapid advances in oncology, and oncology guidelines for rapid recognition and management of these emerging toxicity syndromes are not familiar to emergency physicians. In this review article, we discuss the clinical presentation and management of immune-related adverse effects during the critical first hours of emergency care. We also suggest a workflow for the recognition and treatment of emergencies arising from serious immune-related adverse effects, including but not limited to colitis, adrenal crisis, myocarditis, pneumonitis, myasthenic crisis, diabetic ketoacidosis, bullous pemphigus, and hemophagocytic lymphohistiocytosis. Rapid advances in cancer therapy are bringing new diagnostic and therapeutic challenges to emergency providers, and therefore it is crucial to raise awareness and provide guidelines for the management of new treatment-related toxicities.
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Affiliation(s)
- Sai‐Ching Jim Yeung
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Aiham Qdaisat
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Patrick Chaftari
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Demis Lipe
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jeffrey Merlin
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Eva Rajha
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Adriana Wechsler
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Marcelo Sandoval
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jayne Viets
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Aisha Al‐Breiki
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Mohsin Shah
- Center for Clinical Epidemiology and BiostatisticsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ramesh Pandey
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Mona Kamal
- Department of Symptom ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Clinical Oncology and Nuclear MedicineFaculty of MedicineAin Shams UniversityCairoEgypt
| | - Osama Khattab
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Katy Toale
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Monica Wattana
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ahmed Elsayem
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Susan Gaeta
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Patricia Brock
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Cielito Reyes‐Gibby
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Kumar Alagappan
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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29
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Szymaniak BM, Facchini LA, Giri VN, Antonarakis ES, Beer TM, Carlo MI, Danila DC, Dhawan M, George D, Graff JN, Gupta S, Heath E, Higano CS, Liu G, Molina AM, Paller CJ, Patnaik A, Petrylak DP, Reichert Z, Rettig MB, Ryan CJ, Taplin ME, Vinson J, Whang YE, Morgans AK, Cheng HH, McKay RR. Practical Considerations and Challenges for Germline Genetic Testing in Patients With Prostate Cancer: Recommendations From the Germline Genetics Working Group of the PCCTC. JCO Oncol Pract 2020; 16:811-819. [PMID: 32986533 PMCID: PMC7735040 DOI: 10.1200/op.20.00431] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Germline genetic testing is now routinely recommended for patients with prostate cancer (PCa) because of expanded guidelines and options for targeted treatments. However, integrating genetic testing into oncology and urology clinical workflows remains a challenge because of the increased number of patients with PCa requiring testing and the limited access to genetics providers. This suggests a critical unmet need for genetic services outside of historical models. This review addresses current guidelines, considerations, and challenges for PCa genetic testing and offers a practical guide for genetic counseling and testing delivery, with solutions to help address potential barriers and challenges for both providers and patients. As genetic and genomic testing become integral to PCa care, developing standardized systems for implementation in the clinic is essential for delivering precision oncology to patients with PCa and realizing the full scope and impact of genetic testing.
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Affiliation(s)
- Brittany M. Szymaniak
- Department of Urology, Feinberg School of Medicine at Northwestern University, Chicago, IL
| | | | | | | | - Tomasz M. Beer
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Maria I. Carlo
- Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel C. Danila
- Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mallika Dhawan
- Division of Hematology/Oncology, University of California San Francisco, CA
| | - Daniel George
- Division of Medical Oncology, Department of Medicine, and Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Julie N. Graff
- Division of Hematology and Medical Oncology, VA Portland Health Care System/Oregon Health & Science University Knight Cancer Institute, Portland, OR
| | - Shilpa Gupta
- Division of Hematology, Oncology, and Transplantation, University of Minnesota Masonic Cancer Center, Minneapolis, MN
| | - Elisabeth Heath
- Karmanos Cancer Institute and Department of Oncology, Wayne State University, Detroit, MI
| | - Celestia S. Higano
- Fred Hutchinson Cancer Research Center and Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Glenn Liu
- University of Wisconsin, Madison, WI
| | - Ana M. Molina
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | | | - Akash Patnaik
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, IL
| | | | - Zachery Reichert
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI; University of Michigan Rogel Cancer Center, Ann Arbor, MI
| | - Matthew B. Rettig
- Division of Hematology-Oncology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - Charles J. Ryan
- Division of Hematology, Oncology, and Transplantation, University of Minnesota Masonic Cancer Center, Minneapolis, MN
| | - Mary-Ellen Taplin
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Jake Vinson
- The Prostate Cancer Clinical Trials Consortium, New York, NY
| | - Young E. Whang
- Department of Medicine, Hematology/Oncology, University of North Carolina Lineberger Cancer Center, Chapel Hill, NC
| | - Alicia K. Morgans
- Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, IL
| | - Heather H. Cheng
- Fred Hutchinson Cancer Research Center and Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Rana R. McKay
- Department of Medicine, University of California at San Diego Moores Cancer Center, La Jolla, CA
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30
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Yoshikawa Y, Imamura M, Yamaoka K, Kosaka Y, Murakami E, Morio K, Fujino H, Nakahara T, Okamoto W, Yamauchi M, Kawaoka T, Tsuge M, Hiramatsu A, Hayes CN, Aikata H, Fujitaka K, Arihiro K, Hattori N, Chayama K. A case with life-threatening secondary sclerosing cholangitis caused by nivolumab. Clin J Gastroenterol 2020; 14:283-287. [PMID: 33200345 DOI: 10.1007/s12328-020-01287-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitor (ICI) therapy has potent anti-cancer effects but is associated with immune-related adverse events (irAEs). We present a case who developed secondary sclerosing cholangitis following treatment with nivolumab for non-small cell lung cancer who did not respond to immunosuppressive treatments and died of liver failure. A 75 year-old male with lung cancer who had been treated with nivolumab for non-small cell lung cancer developed Grade 3 liver injury with significant elevation of hepatobiliary enzymes. Magnetic resonance cholangiopancreatography (MRCP) revealed diffuse dilatation of the common bile duct and multifocal stenosis with prestenotic dilatation from the perihilar to intrahepatic bile duct, consistent with sclerosing cholangitis. Histological findings represented an infiltration of mainly CD8-positive T cells around the bile ducts in the liver. Despite treatments with ursodeoxycholic acid, prednisolone, and mycophenolate mofetil, the sclerosing cholangitis did not improve, and the patient died due to liver failure and aggravation of lung cancer. These findings suggest that immune checkpoint inhibitors may lead to resistance to immunosuppressive treatment as well as pose a risk of life-threatening sclerosing cholangitis.
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Affiliation(s)
- Yuki Yoshikawa
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Michio Imamura
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kenji Yamaoka
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yumi Kosaka
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Eisuke Murakami
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kei Morio
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hatsue Fujino
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takashi Nakahara
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Wataru Okamoto
- Cancer Treatment Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Masami Yamauchi
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tomokazu Kawaoka
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Masataka Tsuge
- Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.,Natural Science Center for Basic Research and Development, Hiroshima University, Hiroshima, Japan
| | - Akira Hiramatsu
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Clair Nelson Hayes
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kazunori Fujitaka
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kouji Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan. .,Research Center for Hepatology and Gastroenterology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. .,RIKEN Center for Integrative Medical Sciences, Yokohama, Japan.
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31
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Kamta J, Magruder B, Hymel L. Implementation of a pharmacy consult service for evaluation of immune checkpoint inhibitor related adverse events at a large community hospital. J Oncol Pharm Pract 2020; 27:1821-1828. [PMID: 33176559 DOI: 10.1177/1078155220970266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICI) are novel oncolytic therapies associated with various immune related adverse events (irAEs) affecting multiple organ systems, which may have a delayed presentation. Identification of irAEs and prompt initiation of appropriate treatment represents a challenge to clinicians. The purpose of this study was to evaluate the effectiveness of a pharmacy consult service in identification and management of irAEs.Methodology: This was a single center, retrospective study. Patients included were: ≥18 years old, admitted as inpatients, and reported a history of cancer treatment within the last year. A pharmacy consult was developed and implemented for patients who reported a history of ICI therapy within the last year. Education regarding the consult service was provided to select physicians, nurses, and all pharmacists. Primary outcome: percent of admitted patients reporting ICI therapy within the last year, who required pharmacist intervention for an irAE. Secondary outcomes: types of interventions performed, percentage of recommendation acceptance, pharmacist time spent. RESULTS Fifty-one patients received a pharmacy immunotherapy consult. Seventeen patients (33%) met the primary outcome. Thirty-three separate recommendations were made by pharmacists for these 17 patients. The secondary outcomes of interventions made and percentage accepted (n; % accepted): Initiation/adjustment of steroid therapy (20; 40%), placement of a consult for oncology or other specialist (10; 70%), other therapeutic interventions (3; 67%). Average time spent by pharmacist on initial consultations (SD): 29 minutes (15). CONCLUSION A pharmacy consult service may help to increase identification of patients receiving immune checkpoint inhibitors and initiate timely interventions.
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Affiliation(s)
- Jeff Kamta
- Sarasota Memorial Hospital, Sarasota, FL, USA
| | | | - Lisa Hymel
- Sarasota Memorial Hospital, Sarasota, FL, USA
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32
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Gulati N, Donnelly D, Qian Y, Moran U, Johannet P, Zhong J, Osman I. Revisiting the association between skin toxicity and better response in advanced cancer patients treated with immune checkpoint inhibitors. J Transl Med 2020; 18:430. [PMID: 33176813 PMCID: PMC7659132 DOI: 10.1186/s12967-020-02612-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 11/05/2020] [Indexed: 01/14/2023] Open
Abstract
Background Immune checkpoint inhibition (ICI) improves survival outcomes for patients with several types of cancer including metastatic melanoma (MM), but serious immune-related adverse events requiring intervention with immunosuppressive medications occur in a subset of patients. Skin toxicity (ST) has been reported to be associated with better response to ICI. However, understudied factors, such as ST severity and potential survivor bias, may influence the strength of these observed associations. Methods To examine the potential confounding impact of such variables, we analyzed advanced cancer patients enrolled prospectively in a clinicopathological database with protocol-driven follow up and treated with ICI. We tested the associations between developing ST, stratified as no (n = 617), mild (n = 191), and severe (n = 63), and progression-free survival (PFS) and overall survival (OS) in univariable and multivariable analyses. We defined severe ST as a skin event that required treatment with systemic corticosteroids. To account for the possibility of longer survival associating with adverse events instead of the reverse, we treated ST as a time-dependent covariate in an adjusted model. Results Both mild and severe ST were significantly associated with improved PFS and OS (all P < 0.001). However, when adjusting for the time from treatment initiation to time of skin event, severe ST was not associated with PFS benefit both in univariable and multivariable analyses (P = 0.729 and P = 0.711, respectively). Receiving systemic steroids for ST did not lead to significant differences in PFS or OS compared to patients who did not receive systemic steroids. Conclusions Our data reveal the influence of time to event and its severity as covariates in analyzing the relationship between ST and ICI outcomes. These differences in outcomes cannot be solely explained by the use of immunosuppressive medications, and thus highlight the importance of host- and disease-intrinsic factors in determining ICI response and toxicity. Trial registration: The patient data used in this manuscript come from patients who were prospectively enrolled in two institutional review board-approved databases at NYU Langone Health (institutional review board #10362 and #S16-00122).
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Affiliation(s)
- Nicholas Gulati
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Douglas Donnelly
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Yingzhi Qian
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Una Moran
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Paul Johannet
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Judy Zhong
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Iman Osman
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA.
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33
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Mae S, Kuriyama A, Tachibana H. Diabetic Ketoacidosis as a Delayed Immune-Related Event after Discontinuation of Nivolumab. J Emerg Med 2020; 60:342-344. [PMID: 33097350 DOI: 10.1016/j.jemermed.2020.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/06/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Nivolumab, an anti-programmed cell death-1 (PD-1) monoclonal antibody with immune checkpoint inhibitory activity, represents a novel treatment for several cancers. Immune checkpoint inhibitors cause side effects, known as immune-related adverse events (irAEs) or delayed immune-related events (DIRE), after immunotherapy discontinuation. Type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis have been reported to develop as an irAE during the treatment with nivolumab. Here, we report on a patient who developed T1DM and diabetic ketoacidosis after discontinuation of treatment with nivolumab as a DIRE. CASE REPORT A 59-year-old man, who received nivolumab for an alpha fetoprotein-producing gastric cancer, presented with acute fatigue 4 months after discontinuation of nivolumab. Throughout therapy with nivolumab, the patient's hemoglobin A1c (HbA1c) level was ≤ 6%. However, 1 month prior to the patient's emergency department visit, he noticed weight loss, and 3 weeks prior to that, his HbA1c was 7.1%. Urinalysis showed ketone bodies, and arterial blood gas analysis suggested metabolic acidosis with hyperglycemia (690 mg/dL), which established the diagnosis of diabetic ketoacidosis. An endogenous insulin deficiency without verifiable anti-islet autoantibodies was confirmed; the patient had a human leukocyte antigen haplotype that does not increase the risk of acute-onset T1DM. We considered that T1DM in this patient developed possibly due to nivolumab. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the need for clinicians to be vigilant of the fact that a history of anti-PD-1 monoclonal antibody therapy may increase the risk of diabetic ketoacidosis, whether treatment is ongoing or discontinued.
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Affiliation(s)
- Soichiro Mae
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Hiromi Tachibana
- Department of Diabetic Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
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Durrechou Q, Domblides C, Sionneau B, Lefort F, Quivy A, Ravaud A, Gross-Goupil M, Daste A. Management of Immune Checkpoint Inhibitor Toxicities. Cancer Manag Res 2020; 12:9139-9158. [PMID: 33061607 PMCID: PMC7533913 DOI: 10.2147/cmar.s218756] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/07/2020] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have radically changed the clinical outcome of several cancers with durable responses. CTLA-4 (cytotoxic T lymphocyte antigen-4), PD-1 (programmed cell death protein 1) or PDL-1 (programmed cell death ligand protein 1) represent ICIs that can be used as monotherapy or in combination with other agents. The toxicity p\rofiles of ICIs differ from the side effects of cytotoxic agents and come with new toxicities like immune-related adverse events. Typically, these toxicities occur in all organs. However, the main organs affected are the skin, digestive, hepatic, lungs, rheumatologic, and endocrine. Most of the immune toxicity that occurs is low grade but some more severe toxicities can occur that require a rapid diagnosis and appropriate treatment. The recognition of symptoms by physicians and patient is necessary to resolve them rapidly and adapt treatment to allow the toxicity to resolve.
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Affiliation(s)
- Quentin Durrechou
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Charlotte Domblides
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France.,ImmunoConcEpt, CNRS UMR 5164, Bordeaux University, Bordeaux 33076, France
| | - Baptiste Sionneau
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Felix Lefort
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Amandine Quivy
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Alain Ravaud
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Marine Gross-Goupil
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Amaury Daste
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
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35
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Construction of Genetically Modified Lactococcus lactis Producing Anti-human-CTLA-4 Single-Chain Fragment Variable. Mol Biotechnol 2020; 62:572-579. [PMID: 32960405 DOI: 10.1007/s12033-020-00274-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 12/31/2022]
Abstract
Lactic acid bacteria are human commensal organisms that have immunomodulatory and metabolism-promoting effects. In addition, due to the increasing demand for biopharmaceuticals, genetically modified lactic acid bacteria (gmLAB) that produce recombinant proteins are expected to be used as microbial therapeutics and next-generation probiotics. In this study, we constructed a gmLAB strain that produces anti-human cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) single-chain fragment variable (CTLA4scFv) for possible use in a cancer treatment strategy using gmLAB. CTLA-4, an immune checkpoint molecule, suppresses the anti-cancer immune response; thus, inhibition of CTLA-4 signaling is important in cancer therapy. In this study, we designed a CTLA4scFv composed of a heavy and light chain of the variable region from anti-human CTLA-4 antibody connected by a flexible peptide linker. CTLA4scFv was expressed using nisin controlled gene expression (NICE) system, a lactococcal inducible gene expression system, and the DNA sequence encoding CTLA4scFv was inserted downstream of the PnisA promoter of the gene expression vector pNZ8148#2. Furthermore, expression of recombinant CTLA4scFv was confirmed by Western blotting, and the immunoreactivity of recombinant CTLA4scFv against human CTLA-4 protein was examined using ELISA. We speculate that gmLAB producing bioactive CTLA4scFv will become an attractive approach for cancer treatment.
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Improved survival in patients with thyroid function test abnormalities secondary to immune-checkpoint inhibitors. Cancer Immunol Immunother 2020; 70:299-309. [DOI: 10.1007/s00262-020-02664-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
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Immune checkpoint inhibitors and tuberculosis: an old disease in a new context. Lancet Oncol 2020; 21:e55-e65. [PMID: 31908308 DOI: 10.1016/s1470-2045(19)30674-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 12/17/2022]
Abstract
Tuberculosis, the leading cause of infection-related death in developing regions, is a leading cause of morbidity and mortality worldwide. Screening for, and treatment of, latent Mycobacterium tuberculosis infection is routine before initiation of anti-tumour necrosis factor α (anti-TNFα) agents in the management of psoriasis, Crohn's disease, and rheumatoid arthritis. By contrast, screening for latent tuberculosis before immune checkpoint inhibitor treatment in cancer is not routine, despite the increasing number of reports of primary infection with M tuberculosis or reactivation of latent M tuberculosis infection during such treatment. We present our experience with M tuberculosis screening in 70 patients who underwent immune checkpoint inhibitor therapy for metastatic skin cancer. Based on our understanding of the interaction between M tuberculosis and the immune system, we present the argument for tuberculosis screening before immune checkpoint inhibitor therapy and its use when considering anti-TNFα treatment for severe immune-related adverse events. We call for increased vigilance during immune checkpoint inhibition until its effects on tuberculosis pathophysiology are fully ascertained.
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Brigida M, Perricelli A, Sposato F, Spadafora MG, Pomillo A, Sisto M. Management of Immunotherapy Adverse Events in Oncological Patients: Anti-CTLA-4, Anti-PD-1/PD-L1. Rev Recent Clin Trials 2020; 15:339-346. [PMID: 32568023 DOI: 10.2174/1574887115666200622161418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/02/2020] [Accepted: 05/02/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The widespread use of immunotherapy drugs in the oncological field has led to the spread of new toxicities compared to the more common chemotherapy treatments. This is because immunotherapy with anti-CTLA-4 (Cytotoxic T Lymphocytes-Associated Antigen 4), anti- PD-1 and anti-PD-L1 monoclonal antibodies has become the standard-of-care in a growing number of indications. Any organ or tissue can be involved, but more commonly, side effects are reported regarding skin, colon, endocrine glands, liver, lung and kidney. Other less frequent, but more serious, adverse events are neurological and myocarditis. METHODS We performed an electronic search on PUBMED of the literature concerning immunotherapy- related toxicities and their management in oncological patients from 2007 to 2020, with particular attention to the most recent publications. AIM To summarize the different types of immunotherapy-related toxicities, together with their incidence and diagnosis, and to simplify their management, especially in the emergency setting. CONCLUSION Usually, for grade I toxicities, it is not recommended to stop immunotherapy; for most of grade II toxicities, immunotherapy should be postponed to when toxicity will have regressed to grade I, considering the possibility of corticosteroid treatment for most toxicities. The majority of grade III and IV require administration of high-dose corticosteroid intravenous therapy and suspension of immunotherapy. Mortality related to immune checkpoint inhibitors' toxicity, occurring at a rate of 0.3-1.3%, is well below fatality rates due to other oncologic interventions and should not discourage the promising results so far reached by immunotherapy.
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Affiliation(s)
- Mattia Brigida
- Emergency Medicine Department, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Alessia Perricelli
- Medical Oncology Department, Azienda Sanitaria Provinciale, Cosenza, Italy
| | - Fausto Sposato
- Medical Oncology Department, Azienda Sanitaria Provinciale, Cosenza, Italy
| | | | - Angelo Pomillo
- Medical Oncology Department, Azienda Sanitaria Provinciale, Cosenza, Italy
| | - Milito Sisto
- Medical Oncology Department, Azienda Sanitaria Provinciale, Cosenza, Italy
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Checkpoint inhibitors (CPI) and autoimmune chronic inflammatory diseases (ACIDs): tolerance and loss of tolerance in the occurrence of immuno-rheumatologic manifestations. Clin Immunol 2020; 214:108395. [DOI: 10.1016/j.clim.2020.108395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/18/2020] [Accepted: 03/25/2020] [Indexed: 12/15/2022]
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Long B, Brém E, Koyfman A. Oncologic Emergencies: Immune-Based Cancer Therapies and Complications. West J Emerg Med 2020; 21:566-580. [PMID: 32421502 PMCID: PMC7234690 DOI: 10.5811/westjem.2020.1.45898] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 12/14/2022] Open
Abstract
Cancer therapies have undergone several recent advancements. Current cancer treatments include immune-based therapies comprised of checkpoint inhibitors, and adoptive immunotherapy; each treatment has the potential for complications that differ from chemotherapy and radiation. This review evaluates immune-based therapies and their complications for emergency clinicians. Therapy complications include immune-related adverse events (irAE), cytokine release syndrome (CRS), autoimmune toxicity, and chimeric antigen receptor (CAR) T-cell-related encephalopathy syndrome (CRES). Immune-related adverse events are most commonly encountered with checkpoint inhibitors and include dermatologic complications, pneumonitis, colitis/diarrhea, hepatitis, and endocrinopathies. Less common irAEs include nephritis, myocardial injury, neurologic toxicity, ocular diseases, and musculoskeletal complications. CRS and CRES are more commonly associated with CAR T-cell therapy. CRS commonly presents with flu-like illness and symptoms resembling sepsis, but severe myocardial and pulmonary disease may occur. Critically ill patients require resuscitation, broad-spectrum antibiotics, and hematology/oncology consultation.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Elizabeth Brém
- University of California, Irvine Health, Division of Hematology/Oncology, Orange, California
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
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Rajha E, Pillow MT, Brock PA, Jenks S. Oncologic emergencies in the emergency medicine residency curriculum: A national survey. Am J Emerg Med 2020; 38:2477-2481. [PMID: 32178896 DOI: 10.1016/j.ajem.2020.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/25/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- E Rajha
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - M T Pillow
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - P A Brock
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Jenks
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
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Immunotherapy and Targeted Drugs for Common Cancers. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Rajha E, Chaftari P, Kamal M, Maamari J, Chaftari C, Yeung SCJ. Gastrointestinal adverse events associated with immune checkpoint inhibitor therapy. Gastroenterol Rep (Oxf) 2020; 8:25-30. [PMID: 32104583 PMCID: PMC7034236 DOI: 10.1093/gastro/goz065] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/10/2019] [Accepted: 11/10/2019] [Indexed: 12/12/2022] Open
Abstract
Immunotherapy with checkpoint inhibitors has revolutionized cancer therapy and is now the standard treatment for several different types of cancer, supported by favorable outcomes and good tolerance. However, it is linked to multiple immune manifestations, referred to as immune-related adverse events (irAEs). These adverse events frequently affect the skin, colon, endocrine glands, lungs, and liver. The gastrointestinal system is one of the most commonly affected organ systems and is responsible for the most frequent emergency visits resulting from irAEs. However, because immune checkpoint inhibitors are a recent addition to our arsenal of cancer drugs, many health-care providers remain unfamiliar with the management of irAEs. Gastroenterologists involved in the treatment of oncology patients who have received checkpoint inhibitors are currently encountering cases of abdominal pain, diarrhea, and other nonspecific symptoms that may be challenging to manage. This article reviews the gastrointestinal, hepatic, and pancreatic toxicities of checkpoint inhibitors and provides an approach to their diagnosis and recommended workup. It also highlights the management of irAEs according to their toxicity grading and specifically discusses the instances in which corticosteroids should be administered and/or the immune checkpoint inhibitors should be withheld.
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Affiliation(s)
- Eva Rajha
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mona Kamal
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Julian Maamari
- Schoool of Medicine, Lebanese American University, Byblos, Lebanon
| | - Christopher Chaftari
- Biomedical Engineering, College of Engineering, Texas A&M University, College Station, TX, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Okawa S, Fujiwara K, Shimonishi A, Matsuura H, Ozeki T, Nishimura J, Kayatani H, Minami D, Shinno Y, Sato K, Ota K, Shibayama T. Rapidly Progressive Acute Kidney Injury Associated with Nivolumab Treatment. Case Rep Oncol 2020; 13:85-90. [PMID: 32110225 PMCID: PMC7036533 DOI: 10.1159/000505235] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/28/2019] [Indexed: 12/11/2022] Open
Abstract
A 63-year-old man with pulmonary adenocarcinoma was treated with nivolumab. High fever developed within several hours after the first administration of nivolumab; subsequently, serum creatinine levels kept increasing daily. We diagnosed acute kidney injury (AKI) as an immune-related adverse event; the patient was initially treated with 50 mg prednisolone, and the dose was then tapered. Renal biopsy pathologically revealed tubulointerstitial inflammation with strong infiltration of only T cells that were CD3+, CD4+, and CD8+. The infiltration of CD163+ M2 macrophage was also observed. AKI within 1 week after the administration of nivolumab seems to be rare; therefore, the present case provides important findings useful in daily clinical practice.
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Affiliation(s)
- Sachi Okawa
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Keiichi Fujiwara
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Atsushi Shimonishi
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiroaki Matsuura
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Taichi Ozeki
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Jun Nishimura
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiroe Kayatani
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Daisuke Minami
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yoko Shinno
- Department of Pathology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Ken Sato
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Kosuke Ota
- Department of Nephrology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takuo Shibayama
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
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Webster KA, O'Connor ML, Hansen AR, Kircher S, Jim HSL, Dicker AP, Janda M, Ala-Leppilampi K, Bingham CO, Feliciano J, Lynn Henry N, Steffen McLouth LE, Cella D. Development of a Functional Assessment of Chronic Illness Therapy item library and primary symptom list for the assessment of patient-reported adverse events associated with immune checkpoint modulators. JOURNAL OF CANCER METASTASIS AND TREATMENT 2020; 6. [PMID: 34790879 PMCID: PMC8594877 DOI: 10.20517/2394-4722.2019.38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Aim: To develop a comprehensive item library of patient-reported, immunotherapy-related adverse events (irAEs) that draws from and expands on the Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System. Methods: Literature review and iterative expert input. Based on a literature review of irAEs, we developed a framework of immunotherapy classes and their associated symptoms. Clinical experts then reviewed iterations of symptom summaries and item maps linked to the immunotherapy framework. Experts provided content review and feedback was shared across experts until consensus was reached. The iterative process facilitated creation of a Primary Symptom List associated with immune checkpoint modulators (ICMs), drawn from the larger set of symptoms. Existing FACIT items were mapped to the symptom list, and new items were written as needed to create the item library. Results: The full item library of irAEs is comprised of 239 items, covering 142 unique symptoms across 75 inflammatory reactions/immune conditions. A subset of 66 items comprises a Primary Symptom List considered most common/relevant to ICM treatment. This includes gastrointestinal, skin, pulmonary, neurologic, musculoskeletal, and multiple miscellaneous and constitutional symptoms. Conclusion: The FACIT Immunotherapy Item Library is a compilation of 239 self-report items that capture the wide range of AEs experienced by people receiving immune treatments. A subset of 66 items comprises a Primary Symptom List meant for ICM therapy. Use of items selected from this library is encouraged in clinical research and clinical practice evaluation.
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Affiliation(s)
- Kimberly A Webster
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Mary L O'Connor
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Aaron R Hansen
- Princess Margaret Cancer Center, University Health Network, Toronto M5G 1Z5, Canada
| | - Sheetal Kircher
- Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL 60611, USA
| | - Heather S L Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College and Cancer Center at Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Monika Janda
- Centre for Health Services Research, The University of Queensland, QLD 4102, Australia
| | - Kari Ala-Leppilampi
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto M5B 1W8, Canada
| | - Clifton O Bingham
- Divisions of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University, Baltimore, MD 21224, USA
| | - Josephine Feliciano
- Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21231, USA
| | - Norah Lynn Henry
- University of Michigan Rogel Cancer Center, Ann Arbor, MI 48109, USA
| | - Laurie E Steffen McLouth
- Department of Behavioral Science, Center for Health Equity Transformation and Markey Cancer Center, University of Kentucky College of Medicine, Lexington, KY 40536, USA
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Yokobori T, Yazawa S, Asao T, Nakazawa N, Mogi A, Sano R, Kuwano H, Kaira K, Shirabe K. Fucosylated α 1-acid glycoprotein as a biomarker to predict prognosis following tumor immunotherapy of patients with lung cancer. Sci Rep 2019; 9:14503. [PMID: 31601857 PMCID: PMC6787216 DOI: 10.1038/s41598-019-51021-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 09/24/2019] [Indexed: 02/06/2023] Open
Abstract
Immunotherapy targeting immune checkpoint molecules has provided remarkable clinical benefits in cancer patients but no clinically relevant biomarker for predicting treatment outcomes exists. Recently, we demonstrated that glycan structures of serum α1-acid glycoprotein (AGP) changed dramatically in cancer patients and that α1,3fucosylated AGP (fAGP) levels increased along with disease progression and decreased responding to chemotherapy treatments. Here, the fAGP was analyzed in sera prospectively obtained from 39 patients with advanced lung cancer who underwent immunotherapy with anti-PD-1 antibody, nivolumab. Twenty-three patients had significantly high fAGP levels above the cut-off value (H-fAGP) at one month after starting the treatment and 20 patients in this group, whose tumor sizes did not decrease, maintained high fAGP levels continuously and subsequently died. However, the other 16 patients, whose fAGP levels decreased or maintained below the cut-off value (L-fAGP), survived during a 2-year observation even though 5 patients in this group had no tumor shrinkage. Accordingly, the overall survival rate was found to significantly correlate with the fAGP level. Multivariate analyses revealed that the H-fAGP was an independent risk factor for cancer progression. Therefore, the fAGP level appeared to be a reliable biomarker for predicting clinical efficacy of immunotherapy with nivolumab.
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Affiliation(s)
- Takehiko Yokobori
- Department of Innovative Cancer Immunotherapy, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Shin Yazawa
- Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan.
| | - Takayuki Asao
- Gunma University Initiative for Advanced Research (GIAR), Maebashi, Japan
| | - Nobuhiro Nakazawa
- Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Akira Mogi
- Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Rie Sano
- Department of Legal Medicine, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Kyoichi Kaira
- Department of Respiratory Medicine, Comprehensive Cancer Center, International Medical Center, Saitama University Hospital, Hidaka, Japan
| | - Ken Shirabe
- Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
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Peyrony O, Tieghem Y, Fontaine JP. Hypophysite et hépatite secondaires à une immunothérapie par inhibiteur des points de contrôle. ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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48
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Nguyen EE, Winokur E. Immunotherapy Adverse Events: An Emergency Nursing Perspective. J Emerg Nurs 2019; 45:699-706. [PMID: 31402127 DOI: 10.1016/j.jen.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/30/2019] [Accepted: 06/12/2019] [Indexed: 01/07/2023]
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49
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Zhou S, Khanal S, Zhang H. Risk of immune-related adverse events associated with ipilimumab-plus-nivolumab and nivolumab therapy in cancer patients. Ther Clin Risk Manag 2019; 15:211-221. [PMID: 30774357 PMCID: PMC6362938 DOI: 10.2147/tcrm.s193338] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose The aim of this study was to evaluate the risk of immune-related adverse events (irAEs) among cancer patients receiving nivolumab-plus-ipilimumab therapy and nivolumab monotherapy. Patients and methods PubMed and Web of Science were searched for related studies from inception to June 2018. Eligible studies included randomized controlled trials comparing nivolumab-plus-ipilimumab with nivolumab alone in cancer patients reporting on all-grade (grade 1-4) and high-grade (grade 3/4) irAEs. Paired reviewers selected studies for inclusion and extracted data. The odds risk and 95% CI were calculated. Results A total of 2,946 patients from four studies were included in the meta-analysis. The underlying malignancies included lung cancer (two trials) and melanoma (two trials). Compared with nivolumab monotherapy, the nivolumab-plus-ipilimumab therapy was associated with a significantly higher risk of all- and high-grade irAEs such as pruritus, rash, diarrhea, colitis, alanine aminotransferase elevation, and pneumonitis. Conclusion The combination therapy of nivolumab and ipilimumab increased the incidence of irAEs in patients with advanced cancer.
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Affiliation(s)
- Shi Zhou
- Department of Oncology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu, People's Republic of China,
| | - Samrat Khanal
- Department of Oncology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu, People's Republic of China,
| | - Haijun Zhang
- Department of Oncology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu, People's Republic of China,
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