Acute and Long-term Adverse Events Associated With Checkpoint Blockade

First-Line Immunotherapy with Check-Point Inhibitors: Prospective Assessment of Cognitive Function

Approximately 40% of patients with cancer are eligible for check-point inhibitor (CPI) therapy. Little research has examined the potential cognitive impact of CPIs. First-line CPI therapy offers a unique research opportunity without chemotherapy-related confounders. The purpose of this prospective, observational pilot was to (1) demonstrate the feasibility of prospective recruitment, retention, and neurocognitive assessment for older adults receiving first-line CPI(s) and (2) provide preliminary evidence of changes in cognitive function associated with CPI(s). Patients receiving first-line CPI(s) (CPI Group) were assessed at baseline (n = 20) and 6 months (n = 13) for self-report of cognitive function and neurocognitive test performance. Results were compared to age-matched controls without cognitive impairment assessed annually by the Alzheimer's Disease Research Center (ADRC). Plasma biomarkers were measured at baseline and 6 months for the CPI Group. Estimated differences for CPI Group scores prior to initiating CPIs (baseline) trended to lower performance on the Montreal Cognitive Assessment-Blind (MOCA-Blind) test compared to the ADRC controls (p = 0.066). Controlling for age, the CPI Group's 6-months MOCA-Blind performance was lower than the ADRC control group's 12-months performance (p = 0.011). No significant differences in biomarkers were detected between baseline and 6 months, although significant correlations were noted for biomarker change and cognitive performance at 6 months. IFNγ, IL-1β, IL-2, FGF2, and VEGF were inversely associated with Craft Story Recall performance (p < 0.05), e.g., higher levels correlated with poorer memory performance. Higher IGF-1 and VEGF correlated with better letter-number sequencing and digit-span backwards performance, respectively. Unexpected inverse correlation was noted between IL-1α and Oral Trail-Making Test B completion time. CPI(s) may have a negative impact on some neurocognitive domains and warrant further investigation. A multi-site study design may be crucial to fully powering prospective investigation of the cognitive impact of CPIs. Establishment of a multi-site observational registry from collaborating cancer centers and ADRCs is recommended.

Hematological toxicities of immune checkpoint inhibitors and the impact of blood transfusion and its microbiome on therapeutic efficacy and recipient's safety and survival outcome:A systematic narrative appraisal of where we are now!

Classically, patients with solid and hematologic malignancies have been treated with a combination of chemotherapy with or without a holistic targeted strategy using approved conventional therapy. While the evidence-based use of Immunomodulatory drugs and Immune checkpoint inhibitors (ICIs), including those targeting the PD-1, PD-L1 and CTLA-4, have reshaped the treatment paradigm for many malignant tumors and significantly stretched the life expectancy of patients, as for any interventional therapy, the rise in ICI applications, was associated with the observation of more immune-related hematological adverse events. Many of these patients require transfusion support during their treatment in line with precision transfusion. It has been presumed that transfusion-related immunomodulation (TRIM) and the microbiome can pose immunosuppressive effects on the recipients. Looking to the past and beyond and translating available data into practice in the evolving role of pharmaceutical therapy to ICI-receiving patients, we performed a narrative review of the literature on the immune-related hematological adverse events of ICIs, immunosuppressive mechanisms linked to blood product transfusions, as well as the detrimental impact of transfusions and its related microbiome on the sustained efficacy of ICIs and the patients' survival outcomes. Recent reports are pointing to the negative impact of transfusion on ICI response. Studies have concluded that packed RBC [PRBC] transfusions lead to an inferior progression-free and overall survival in patients with advanced cancer receiving ICIs, even after adjustments for other prognostic variables. The attenuation of the effectiveness of immunotherapy likely results from the immunosuppressive effects of PRBC transfusions. It is, therefore, wise to look retrospectively and prospectively at the impact of transfusion on ICI effects and adopt, in the interim, a restrictive transfusion strategy, if applicable, for those patients.

Progress in diagnosis and treatment of checkpoint inhibitor pneumonitis

PURPOSE OF REVIEW

In this article, we summarized the current knowledge of the diagnosis and treatment of the checkpoint inhibitor pneumonitis (CIP), and provide an outlook on the current issues and future prospects.

RECENT FINDINGS

Pulmonary toxicity of immunotherapy covers a broad range of pulmonary manifestations and is often referred to as pneumonitis. It is a severe and potentially life-threatening immune-related adverse events (irAEs) that requires early identification and management. The diagnosis of CIP should be carefully distinguished from other forms of pulmonary diseases. Recognizing risk factors and typical symptoms helps to raise suspicion of CIP. Further characterization of the unique radiographic and pathological features is warranted to expedite diagnosis. The identification of potential biomarkers for CIP is emerging and has great relevance in the clinic. Multidisciplinary collaborations involving oncologists, radiologists and pulmonologists may facilitate uniform management strategies. Treatment discontinuation is the mainstay for treating CIP of all grades. Systemic steroids are considered for pneumonitis at least grade 2 and immunosuppressive drugs are recommended for CIP patients refractory to steroids. In the future, more diagnosis and management strategies are needed to provide new insights and treatment options.

SUMMARY

There are achievements and shortcomings in the current status of the diagnosis and treatment for CIP. In the future, the research on this topic should be further demonstrated.

Exploring the educational needs for severe immune-related adverse events of PD-1/PD-L1 inhibitors in advanced lung cancer : A single-center observational study

Objective

With the expanded use of immunotherapy in medical oncology, effective patient education regarding immune-related adverse events (irAEs) is crucial for oncology nursing. Therefore, this study aimed to identify educational needs for preventing unscheduled hospitalizations due to severe irAEs.

Methods

We retrospectively reviewed the medical records of 159 consecutive patients with lung cancer who received programmed cell death-1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors in 2020. We evaluated the frequency, severity, and unscheduled hospitalization due to irAEs based on the PD-1/PD-L1 inhibitor use. Educational needs were assessed based on initial symptoms, reporters, telephone consultation, and the time lag between symptom onset and hospital visit.

Results

Among 159 patients evaluable for irAEs, 73 (45.9%) experienced 91 irAEs during the study period. Seventeen patients (10.7%) required unscheduled hospitalization due to severe irAEs after a median duration of 4.1 days from symptom onset, and 52.9% visited hospitals after telephone consultations from caregivers. Pneumonitis (10 events) was the most frequent irAE requiring hospitalization, followed by adrenal insufficiency (three events). The type and severity of irAEs varied based on PD-1/PD-L1 inhibitor use.

Conclusions

The frequency of severe irAEs requiring hospitalization was high in patients who received PD-1/PD-L1 inhibitors for advanced lung cancer. The early detection of severe irAEs may be possible through education focusing on common irAEs that are potentially severe. Patients and caregivers should be aware of the importance of reporting slight changes in symptoms after PD-1/PD-L1 therapy initiation in a timely manner. Healthcare professionals need to acknowledge common irAEs and be qualified to implement systematic telephone triage of irAEs.

Activating the Antitumor Immune Response in Non-Hodgkin Lymphoma Using Immune Checkpoint Inhibitors

Non-Hodgkin lymphomas comprise a heterogenous group of disorders which differ in biology. Although response rates are high in some groups, relapsed disease can be difficult to treat, and newer approaches are needed for this patient population. It is increasingly apparent that the immune system plays a significant role in the propagation and survival of malignant cells. Immune checkpoint blocking agents augment cytotoxic activity of the adaptive and innate immune systems and enhance tumor cell killing. Anti-PD-1 and anti-CTLA-4 antibodies have been tested as both single agents and combination therapy. Although success rates with anti-PD-1 antibodies are high in patients with Hodgkin lymphoma, the results are yet to be replicated in those with non-Hodgkin lymphomas. Some lymphoma histologies, such as primary mediastinal B cell lymphoma (PMBL), central nervous system, and testicular lymphomas and gray zone lymphoma, respond favorably to PD-1 blockade, but the response rates in most lymphoma subtypes are low. Other agents including those targeting the adaptive immune system such as TIM-3, TIGIT, and BTLA and innate immune system such as CD47 and KIR are therefore in trials to test alternative ways to activate the immune system. Patient selection based on tumor biology is likely to be a determining factor in treatment response in patients, and further research exploring optimal patient populations, newer targets, and combination therapy as well as identifying biomarkers is needed.

A drug delivery perspective on intratumoral-immunotherapy in renal cell carcinoma

In less than 5years immune checkpoint inhibitors (ICI) went from first FDA approval to become first-line options in advanced renal cell carcinoma. Despite that many patients have benefited from ICI, a significant fraction of individuals are refractory to these new immunological treatments. In this review, we discussed using intratumoral (i.t.) route of drug administration as an alternative to systemic therapy to increase the response rates and to circumvent potential drug-induced systemic adverse events. We provided a historic account of i.t. drug treatments in cancer and reviewed the contemporary experience in local drug delivery. We discussed the potential for enhancing the therapeutic impact of ICI by leveraging hydrogels as drug delivery vehicles and presented an outlook for implementing i.t. in renal cell carcinoma.

Immune checkpoint inhibitor-induced inflammatory arthritis as a model of autoimmune arthritis

The development of inflammatory arthritis in patients receiving immune checkpoint inhibitor therapy is increasingly recognized due to the growing use of these drugs for the treatment of cancer. This represents an important opportunity not only to define the mechanisms responsible for the development of this immune-related adverse event and to ultimately predict or prevent its development, but also to provide a unique window into early events in the development of inflammatory arthritis. Knowledge gained through the study of this patient population, for which the inciting event is known, could shed light into the pathogenesis of autoimmune arthritis. This review will highlight the clinical and immunologic features of these entities to define common elements for future study.