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Townsend MJ, Benque IJ, Li M, Grover S. Review article: Contemporary management of gastrointestinal, pancreatic and hepatic toxicities of immune checkpoint inhibitors. Aliment Pharmacol Ther 2024; 59:1350-1365. [PMID: 38590108 DOI: 10.1111/apt.17980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/13/2023] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are effective oncologic agents which frequently cause immune-related adverse events (irAEs) which can impact multiple organ systems. Onco-Gastroenterology is a novel and emerging subspecialty within gastroenterology focused on cancer treatment-related complications. Gastroenterologists must be prepared to identify and manage diverse immune-mediated toxicities including enterocolitis, hepatitis, pancreatitis and other ICI-induced toxicities. AIM To provide a narrative review of the epidemiology, diagnostic evaluation and management of checkpoint inhibitor-induced gastrointestinal and hepatic toxicities. METHODS We searched Cochrane and PubMed databases for articles published through August 2023. RESULTS Gastrointestinal and hepatic irAEs include most commonly enterocolitis and hepatitis, but also pancreatitis, oesophagitis, gastritis, motility disorders (gastroparesis) and other rarer toxicities. Guidelines from the National Comprehensive Cancer Network, American Society of Clinical Oncology and European Society for Medical Oncology, in combination with emerging cohort and clinical trial data, offer strategies for management of ICI toxicities. Evaluation of irAEs severity by formal classification and clinical stability, and a thorough workup for alternative etiologies which may clinically mimic irAEs underlie initial management. Treatments include corticosteroids, biologics and other immunosuppressive agents plus supportive care; decisions on dosing, timing and choice of steroid adjuncts and potential for subsequent checkpoint inhibitor dosing are nuanced and toxicity-specific. CONCLUSIONS Expanding clinical trial and cohort data have clarified the epidemiology and clinical characteristics of gastrointestinal, pancreatic and hepatic toxicities of ICIs. Guidelines, though valuable, remain based principally on retrospective cohort data. Quality prospective, controlled studies may refine algorithms for treatment and potential immunotherapy rechallenge.
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Affiliation(s)
- Matthew J Townsend
- Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Isaac J Benque
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Michael Li
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Division of Gastroenterology, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Shilpa Grover
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Indini A, Gueli R, Cerati M, Rijavec E, Parravicini M, Casagrande S, Rovelli C, Grossi PA, Grossi F. Cytomegalovirus gastritis as a rare adverse event during combined ipilimumab and nivolumab in a patient with melanoma. Melanoma Res 2024:00008390-990000000-00147. [PMID: 38768445 DOI: 10.1097/cmr.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Immunotherapy has improvedsurvival outcomes of patients with advanced melanoma. Lower gastrointestinal tract immune-related adverse events (irAEs) are common during treatment; however, gastritis is not frequently observed. Herein, we report a case of severe cytomegalovirus (CMV)-related gastritis in a patient treated with ipilimumab and nivolumab for metastatic melanoma. This report presents a 60-year-old woman with stage IV BRAF wild-type melanoma. t. After the second course of ipilimumab-nivolumab, the patient reported epigastric discomfort after meals, anorexia, and subsequent nausea, vomiting, epigastric pain, and weight loss. Disease staging with PET/CT scan showed very good partial response and diffuse gastroduodenitis. The patient underwent esophagogastroduodenoscopy, showing severe esophageal candidiasis and diffuse hemorrhagic, edematous, and ulcerative mucosa in the whole gastric wall. Biopsies of the gastric wall were obtained. Before receipt of the final pathology report, the patient was empirically started on corticosteroids based on the clinical suspicion of immune-related gastritis, without improvement of symptoms. The hematoxylin-eosin staining demonstrated active gastritis with diffuse nuclear cytopathic viral inclusions in epithelial and interstitial cells; CMV infection was confirmed with immunohistochemical staining. The patient startedganciclovir and fluconazole, with rapid improvement of symptoms. This case presents a rare instance of CMV gastritis in a patient receiving combined anti-PD1 and anti-CTLA4 , in the absence of immune-suppression to manage an irAE. In the case of suggestive symptoms of irAEs, a high index of clinical suspicion is required to rule out concomitant or isolated infective disease. Guidelines for prophylaxis and treatment of these patients are needed, to optimize treatment results.
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Affiliation(s)
| | | | | | | | | | - Sabrina Casagrande
- Nuclear Medicine Unit, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi
| | - Cristina Rovelli
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery
| | | | - Francesco Grossi
- Medical Oncology Unit, Department of Medicine and Surgery, University of Insubria, ASST Sette Laghi, Varese, Italy
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Lin J, Lin ZQ, Zheng SC, Chen Y. Immune checkpoint inhibitor-associated gastritis: Patterns and management. World J Gastroenterol 2024; 30:1941-1948. [PMID: 38681126 PMCID: PMC11045486 DOI: 10.3748/wjg.v30.i14.1941] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/23/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are widely used due to their effectiveness in treating various tumors. Immune-related adverse events (irAEs) are defined as adverse effects resulting from ICI treatment. Gastrointestinal irAEs are a common type of irAEs characterized by intestinal side effects, such as diarrhea and colitis, which may lead to the cessation of ICIs. Although irAE gastritis is rarely reported, it may lead to serious complications such as gastrorrhagia. Furthermore, irAE gastritis is often difficult to identify early due to its diverse symptoms. Although steroid hormones and immunosuppressants are commonly used to reverse irAEs, the best regimen and dosage for irAE gastritis remains uncertain. In addition, the risk of recurrence of irAE gastritis after the reuse of ICIs should be considered. In this editorial, strategies such as early identification, pathological diagnosis, management interventions, and immunotherapy rechallenge are discussed to enable clinicians to better manage irAE gastritis and improve the prognosis of these patients.
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Affiliation(s)
- Jing Lin
- Department of Medical Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou 350000, Fujian Province, China
| | - Zhong-Qiao Lin
- Phase I Clinical Trial Ward, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou 350000, Fujian Province, China
| | - Shi-Cheng Zheng
- School of Basic Medical Sciences, Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Yu Chen
- Department of Medical Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou 350000, Fujian Province, China
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Tsukaguchi A, Yamaguchi N, Ogawa H, Ikeda T. Concurrent Nivolumab-Induced Gastritis and Cholangitis Accompanied by Biliary Tract Hemorrhage in a Patient With Stage IV Lung Adenocarcinoma. Cureus 2023; 15:e46392. [PMID: 37927718 PMCID: PMC10620473 DOI: 10.7759/cureus.46392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Immune checkpoint inhibitors, including nivolumab, can result in immune-related adverse events (irAEs) that may affect multiple organ systems. Among irAEs, both gastritis and cholangitis are uncommon. We present the case of a 65-year-old man who received nivolumab for lung adenocarcinoma presented with epigastric pain. He was diagnosed with immune-related gastritis and cholangitis based on imaging and pathological findings. We administered prednisolone (1 mg/kg/day), which improved the patient's gastritis and relieved his pain. However, he experienced recurrent epigastric pain during corticosteroid tapering, and magnetic resonance imaging showed biliary tract hemorrhage. After watchful waiting, the hemorrhage improved without additional immunosuppressants. Immune-related gastritis, immune-related cholangitis, and their coexistence should be considered in patients who develop epigastric pain during immune checkpoint inhibitor therapy. When patients with concurrent immune-related gastritis and cholangitis complain of recurrent epigastric pain, it is important to assess which of these two irAEs is worsening because the optimal immunosuppressants differ between the two.
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Affiliation(s)
- Akihiro Tsukaguchi
- Department of Respiratory Medicine, Nishinomiya Municipal Central Hospital, Nishinomiya, JPN
| | - Norihiko Yamaguchi
- Department of Respiratory Medicine, Nishinomiya Municipal Central Hospital, Nishinomiya, JPN
| | - Hiroyuki Ogawa
- Department of Gastroenterology, Nishinomiya Municipal Central Hospital, Nishinomiya, JPN
| | - Toshiyuki Ikeda
- Department of Respiratory Medicine, Nishinomiya Municipal Central Hospital, Nishinomiya, JPN
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Mathialagan K, Tai CH, Sethi S, Thomas S, Loeser C. Immune Checkpoint Inhibitor-Induced Hemorrhagic Gastritis. ACG Case Rep J 2023; 10:e01128. [PMID: 37583508 PMCID: PMC10424893 DOI: 10.14309/crj.0000000000001128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/18/2023] [Indexed: 08/17/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have been increasingly used in the treatment of several malignancies and may target cytotoxic T-lymphocyte-associated antigen-4, programmed cell death-1, and programmed cell death ligand 1, which work on maintaining peripheral immune tolerance. ICIs inhibit these ligands causing an immune-enhancing effect, leading to a wide spectrum of complications from mild mucositis to life-threatening pneumonitis or hepatitis. These complications are collectively called immune-related adverse events. Their prevalence has increased with a rise in ICI use, with rare manifestations being reported in popular literature. We present a case of hemorrhagic gastritis due to the anti-programmed cell death-1 antibody, pembrolizumab.
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Affiliation(s)
- Karthik Mathialagan
- Department of Medicine, Yale-New Haven Health–Bridgeport Hospital, Bridgeport, CT
| | - Cheng-Hung Tai
- Section of Gastroenterology, Department of Medicine, Yale-New Haven Health–Bridgeport Hospital, Bridgeport, CT
| | - Samdish Sethi
- Department of Medicine, Yale-New Haven Health–Bridgeport Hospital, Bridgeport, CT
| | - Sumi Thomas
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Caroline Loeser
- Section of Gastroenterology, Department of Medicine, Yale-New Haven Health–Bridgeport Hospital, Bridgeport, CT
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Tipton JM. Assessment and management of nausea and vomiting in cancer survivors. Nurse Pract 2023; 48:30-38. [PMID: 37097100 DOI: 10.1097/01.npr.0000000000000039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
ABSTRACT Nausea and vomiting may occur in cancer survivors during or independent of treatment. A complete assessment is necessary to determine the etiology and to plan specific and successful interventions. NPs have a key role in managing cancer survivors' symptoms and determining the best supportive care.
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Affiliation(s)
- Janelle M Tipton
- Janelle M. Tipton is a clinical assistant professor in the School of Nursing at Purdue University in West Lafayette, Ind
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Fukiishi Y, Fukuhara H, Kurano Y, Shugimoto H, Yamashita E, Karasima T, Inoue K. A case of acute lymphocytic gastritis related to treatment with pembrolizumab for metastatic urothelial carcinoma. IJU Case Rep 2023; 6:128-132. [PMID: 36874988 PMCID: PMC9978067 DOI: 10.1002/iju5.12568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Immune checkpoint inhibitors such as programmed cell death/-ligand 1 inhibitor and cytotoxic T-lymphocyte-associated antigen-4 inhibitors have been widely used for various advanced malignancies. The mechanism of action for these inhibitors is the improvement of antitumor immunity via T-cell modulation. On the contrary, immune-related adverse events such as autoimmune colitis might arise in association with T-cell activation. Upper gastrointestinal adverse events related to pembrolizumab have rarely been reported. Case presentation A 72-year-old man underwent laparoscopic radical cystectomy for muscle-invasive bladder cancer (pT2N0M0). Multiple lymph node metastases appeared in the paraaortic region. First-line chemotherapy comprising gemcitabine and carboplatin failed to stop disease progression. After the administration of pembrolizumab as second-line treatment, the patient showed symptomatic gastroesophageal reflux disease. Esophagogastroduodenoscopic biopsy of the gastric body showed severe lymphoplasmacytic and neutrophilic infiltration. Conclusion We present acute gastritis related to pembrolizumab. Early eradication therapy may be able to control immune checkpoint inhibitor-related gastritis.
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Affiliation(s)
- Yousuke Fukiishi
- Department of Urology National Hospital Organization Kochi National Hospital Kochi Japan
| | | | | | | | | | | | - Keiji Inoue
- Department of Urology Kochi Medical School Kochi Japan
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Zheng-Lin B, Faleck DM, Harding JJ. Subacute Abdominal Pain in a Patient With Chronic Liver Disease and Hepatocellular Carcinoma. JAMA Oncol 2022; 8:1688-1689. [PMID: 36136344 DOI: 10.1001/jamaoncol.2022.3888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A 66-year-old woman with chronic hepatitis B infection and hepatocellular carcinoma presented with moderate radiating epigastric pain with nausea, anorexia, and water brash without emesis. What is your diagnosis?
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Affiliation(s)
- Binbin Zheng-Lin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Medical College of Cornell University, New York, New York
| | - David M Faleck
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Medical College of Cornell University, New York, New York
| | - James J Harding
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Medical College of Cornell University, New York, New York
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