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Michot JM, Lazarovici J, Tieu A, Champiat S, Voisin AL, Ebbo M, Godeau B, Michel M, Ribrag V, Lambotte O. Haematological immune-related adverse events with immune checkpoint inhibitors, how to manage? Eur J Cancer 2019; 122:72-90. [PMID: 31634647 DOI: 10.1016/j.ejca.2019.07.014] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 01/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are changing the treatments of many patients with cancer. These immunotherapies are generally better tolerated than chemotherapy, and their adverse events are immune-related mimicking autoimmune or inflammatory conditions. Although these immune-related adverse events mainly affect the skin, endocrine glands, digestive tract, joints, liver or lungs, all the organs can be theoretically affected, and the haematopoietic system is not spared. This review of the literature will focus on the haematological immune-related adverse events (Haem-irAEs). By reviewing the largest clinical trials of ICIs, we estimate the frequency of Haem-irAEs at 3.6% for all grades and 0.7% for grades III-IV. Frequency of Haem-irAEs of all grades was found to be higher with anti-programmed cell death 1 (4.1%) or anti-programmed cell death ligand 1 (4.7%) than with anti-cytotoxic T-lymphocyte-associated protein 4 (0.5%) (p < 0.0001). From the 63 cases with Haem-irAEs reported in the literature, the mean time to the onset was found to be 10 weeks after ICI initiation, and the large range for occurrence (1-84 weeks) and the regular incidence suggest that Haem-irAEs could occur at any time after ICI therapy. Among the 63 reported cases with Haem-irAEs, the distribution was immune thrombocytopenia (n = 18, 29%), pancytopenia or immune aplastic anaemia (n = 12, 19%), neutropenia (n = 11, 17%), haemolytic anaemia (n = 10, 16%), cytokine release syndrome with haemophagocytic syndrome (n = 7, 11%) and other Haem-irAEs including bicytopenia or pure red cell aplasia (n = 5, 8%). Haem-irAEs are generally highly severe adverse reactions with a mortality rate of Haem-irAEs reported to be 14% (9 deaths among the 63 cases reported). The more severe and life-threatening Haem-irAEs were both cytokine release syndrome with haemophagocytic syndrome and pancytopenia or aplastic anaemia. Haem-irAEs induced by ICIs are potentially life-threatening. By discussing their pathophysiological aspects and clinical picture, we propose in this review clinical guidelines for management.
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Affiliation(s)
- J M Michot
- Gustave Roussy, Université Paris-Saclay, Département des Innovations Thérapeutiques et Essais Précoces, Villejuif, F-94805, France; Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, Le Kremlin-Bicêtre, F-94275, France.
| | - J Lazarovici
- Gustave Roussy, Université Paris-Saclay, Département D'Hématologie, Villejuif, F-94805, France
| | - A Tieu
- Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, Le Kremlin-Bicêtre, F-94275, France
| | - S Champiat
- Gustave Roussy, Université Paris-Saclay, Département des Innovations Thérapeutiques et Essais Précoces, Villejuif, F-94805, France
| | - A L Voisin
- Gustave Roussy, Université Paris-Saclay, Unité de Pharmacovigilance, Villejuif, F-94805, France
| | - M Ebbo
- Assistance Publique - Hôpitaux de Marseille, Hôpital de La Timone, Médecine Interne, Marseille, F-13005, France
| | - B Godeau
- Assistance Publique - Hôpitaux de Paris, Hôpital Henri Mondor, Médecine Interne, Centre de Référence des Cytopénies Auto-immunes de L'Adulte, Université Paris-Est Créteil, Créteil, F-94010, France
| | - M Michel
- Assistance Publique - Hôpitaux de Paris, Hôpital Henri Mondor, Médecine Interne, Centre de Référence des Cytopénies Auto-immunes de L'Adulte, Université Paris-Est Créteil, Créteil, F-94010, France
| | - V Ribrag
- Gustave Roussy, Université Paris-Saclay, Département des Innovations Thérapeutiques et Essais Précoces, Villejuif, F-94805, France; Gustave Roussy, Université Paris-Saclay, Département D'Hématologie, Villejuif, F-94805, France
| | - O Lambotte
- Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, Le Kremlin-Bicêtre, F-94275, France; INSERM U1184, Immunology of Viral Infections and Autoimmune Diseases, Le Kremlin-Bicêtre, F-94276, France; Université Paris Sud, UMR 1184, Le Kremlin-Bicêtre, F-94276, France; CEA, DSV/iMETI, IDMIT, Fontenay-aux-Roses, F-92265, France
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Abstract
Secondary autoimmune cytopenias in chronic lymphocytic leukemia are distinct clinical entities that require specific management. These autoimmune disorders have a complex pathogenesis that involves both the leukemic cells and the immune environment in which they exist. The mechanism is not the same in all cases, and to varying degrees involves the chronic lymphocytic leukemia (CLL) cells in antibody production, antigen presentation, and stimulation of T cells and bystander polyclonal B cells. Diagnosis of autoimmune cytopenias can be challenging as it is difficult to differentiate between autoimmunity and bone marrow failure due to disease progression. There is a need to distinguish these causes, as prognosis and treatment are not the same. Evidence regarding treatment of secondary autoimmune cytopenias is limited, but many effective options exist and treatment can be selected with severity of disease and patient factors in mind. With new agents to treat CLL coming into widespread clinical use, it will be important to understand how these will change the natural history and treatment of autoimmune cytopenias.
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Affiliation(s)
- Kerry A Rogers
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jennifer A Woyach
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH.
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Autrel-Moignet A, Lamy T. Autoimmune neutropenia. Presse Med 2014; 43:e105-18. [PMID: 24680423 DOI: 10.1016/j.lpm.2014.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/13/2014] [Accepted: 02/18/2014] [Indexed: 02/08/2023] Open
Abstract
Autoimmune neutropenia (AIN) is a rare entity caused by antibodies directed against neutrophil-specific antigens. It includes primary and secondary autoimmune neutropenia. Acute autoimmune neutropenia can be related to drug-induced mechanism or viral infections. Chronic autoimmune neutropenias occur in the context of autoimmune diseases, hematological malignancies, such as large granular lymphocyte leukemia, primary immune deficiency syndromes or solid tumors. The therapeutic management depends on the etiology. Granulocyte growth factor is the main therapeutic option, raising the question of their long-term utilization safety. Corticosteroids or immunosuppressive therapy are indicated in infection-related AIN or in case of symptomatic autoimmune disease or LGL leukemia.
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Affiliation(s)
| | - Thierry Lamy
- CHU de Rennes, service d'hématologie clinique, Rennes 35043, France; Université Rennes 1, Rennes 35043, France.
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Tandra P, Krishnamurthy J, Bhatt VR, Newman K, Armitage JO, Akhtari M. Autoimmune cytopenias in chronic lymphocytic leukemia, facts and myths. Mediterr J Hematol Infect Dis 2013; 5:e2013068. [PMID: 24363883 PMCID: PMC3867225 DOI: 10.4084/mjhid.2013.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 10/31/2013] [Indexed: 12/21/2022] Open
Abstract
CLL has been defined as presence of more than 5000 small mature appearing monoclonal B lymphocytes with a specific immunophenotype in peripheral blood. It is a well-known fact that CLL is associated with autoimmune cytopenias. CLL cells are CD5(+) B lymphocytes, and usually are not the "guilty" cells which produce autoantibodies. T cell defect is another characteristic of CLL and the total number of T cells is increased, and there is inversion of the CD4/CD8 ratio. Autoimmune hemolytic anemia (AIHA) is the most common autoimmune complication of CLL and has been reported in 10-25% of CLL patients. However, the stage-adjusted estimated rate of AIHA in CLL is about 5%. Conversely, CLL is three times more common in patients who present with AIHA. Direct agglutinin test (DAT) is positive in 7-14% of CLL patients but AIHA may also occur in DAT negative patients. Autoimmune thrombocytopenia (AIT) is the second most common complication of CLL and has been reported in 2-3% of patients. DAT is positive in AIT but presence of antiplatelet antibodies is neither diagnostic nor reliable. Autoimmune neutropenia (AIN) and pure red cell aplasia (PRCA) are very rare complications of CLL and like other autoimmune complications of CLL may occur at any clinical stage. It is believed that most case reports of AIN and PRCA in CLL actually belong to large granular lymphocytic leukemia (LGL). Non-hematologic autoimmune complications of CLL including cold agglutinin disease (CAD), paraneoplastic pemphigus (PNP), acquired angioedema, and anti-myelin associated globulin are rare. Before starting any treatment, clinicians should distinguish between autoimmune cytopenias and massive bone marrow infiltration since autoimmune complications of CLL are not necessarily equal to advanced disease with poor prognosis. According to IWCLL guideline, steroids are the mainstay of treatment of simple autoimmunity. Intravenous immunoglobulin (IVIg), cyclosporine, and rituximab are used in complex, steroid refractory cases. Monotherapy with purine analogues and alkylating agents should be avoided as they may increase CLL associated autoimmune complications.
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Affiliation(s)
- Pavankumar Tandra
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jairam Krishnamurthy
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kam Newman
- Dr. Kam Newman, Section of Transfusion Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue 6-1, Cleveland, OH 44195, USA
| | - James O Armitage
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Mojtaba Akhtari
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
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Trus M, Dhamanaskar K, Potts J, Wasi P, Bains S, Bordeleau L. Adjuvant Chemotherapy for Breast Cancer in a Patient with Primary Autoimmune Neutropenia. BREAST CANCER: BASIC AND CLINICAL RESEARCH 2013; 7:1-6. [PMID: 23440399 PMCID: PMC3572877 DOI: 10.4137/bcbcr.s10767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We report an extremely rare and complex case of a 44-year-old woman diagnosed with an early stage triple negative breast cancer in the setting of primary autoimmune neutropenia with a pre-existing severe neutropenia. This case-report demonstrates that adjuvant chemotherapy for breast cancer can be administered in a patient with severe neutropenia. The management is however complicated and requires careful monitoring of side-effects related to both chemotherapy and treatment of autoimmune neutropenia. The role of chemotherapy in the treatment of triple negative breast cancer, the approach to autoimmune neutropenia and potential interactions are reviewed. To our knowledge, this is the first case reporting on the use of chemotherapy in a patient with severe pre-existing primary autoimmune neutropenia.
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Affiliation(s)
| | | | | | | | - Satvir Bains
- Juravinski Cancer Centre, Hamilton, Ontario, Canada
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