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Pasoto SG, Franco AS, Silva CA, Bonfa E. Sicca syndrome/Sjögren's disease associated with cancer immunotherapy: a narrative review on clinical presentation, biomarkers, and management. Expert Rev Clin Immunol 2024; 20:1149-1167. [PMID: 38903050 DOI: 10.1080/1744666x.2024.2370327] [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: 03/17/2024] [Accepted: 06/17/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION Almost one-quarter of immune checkpoint inhibitor (ICI) recipients experience sicca syndrome, while Sjögren's disease (SjD) is estimated at 0.3-2.5%, possibly underreported. AREAS COVERED This narrative review (Medline/Embase until January/31/2024) addresses the pathophysiology, incidence, demographic/clinical features, biomarkers, labial salivary gland biopsy (LSGB), fulfillment of the idiopathic SjD (iSjD) classificatory criteria, differential diagnosis, and management of sicca syndrome/SjD associated with ICIs. EXPERT OPINION SjD associated with ICIs is underdiagnosed, since studies that performed the mandatory SjD investigation identified that 40-60% of patients with sicca syndrome associated with ICIs meet the iSjD classificatory criteria. LSGB played a fundamental role in recognizing these cases, as most of them had negative anti-Ro/SS-A antibody. Despite the finding of focal lymphocytic sialoadenitis in LSGB samples mimicking iSjD, immunohistochemical analysis provided novel evidence of a distinct pattern for sicca syndrome/SjD associated with ICIs compared to iSjD. The former has scarcity of B lymphocytes, which are a hallmark of iSjD. Additionally, patients with sicca syndrome/SjD associated with ICIs have demographical/clinical/serological and treatment response dissimilarities compared to iSjD. Dryness symptoms are more acute in the former than in iSjD, with predominance of xerostomia over xerophthalmia, and partial/complete response to glucocorticoids. Dryness symptoms in ICI-treated patients warrant prompt SjD investigation.
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Affiliation(s)
- Sandra Gofinet Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - André Silva Franco
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Clovis Artur Silva
- Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Eloisa Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
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Masalkhi M, Wahoud N, Moran B, Elhassadi E. Impact of immune checkpoint inhibitors on vision and eye health. Eye (Lond) 2024; 38:2854-2856. [PMID: 38961146 PMCID: PMC11461837 DOI: 10.1038/s41433-024-03212-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/08/2024] [Accepted: 06/21/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
- Mouayad Masalkhi
- School of Medicine, University College Dublin, Belfield, Dublin, Ireland.
| | - Noura Wahoud
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Bridget Moran
- Mater Miscordiae University Hospital, Dublin, Ireland
| | - Ezzat Elhassadi
- Haematology Department, University Hospital Waterford, Waterford, Ireland
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Pichon S, Aigrain P, Lacombe C, Lemarchant B, Ledoult E, Koether V, Leurs A, Zebian G, Launay D, Gachet B, Levy C. Immune checkpoint inhibitors-associated cranial nerves involvement: a systematic literature review on 136 patients. J Neurol 2024; 271:6514-6525. [PMID: 39225744 PMCID: PMC11446990 DOI: 10.1007/s00415-024-12660-2] [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: 07/13/2024] [Revised: 08/20/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE Describe the demographic data and clinical phenotype of cranial palsy induced by immune checkpoint inhibitors (CNP-ICI). METHODS A systematic literature review of the literature was performed in Pubmed, Web of Science, and Embase, including 68 articles and 136 patients (PROSPERO no. CRD42024517262). RESULTS Out of the 1205 articles screened, 68 articles were included after fulfilling the inclusion criteria, for a total of 136 patients. All articles were case reports and case series. In the cohort studied, 52% of patients were treated with anti PD-1/PDL-1 therapies, 14% with anti CTLA-4 therapies, and 34% with a combination of anti CTLA-4 and anti PD-1/PDL-1 therapies. The facial nerve was the most affected cranial nerve, involved in 38% of cases, followed by the optic nerve (35%), the cochleovestibular nerve (12%), and the abducens nerve (10%). The median time from the initial immune checkpoint inhibitor (ICI) injection to the onset CNP-ICI was 10 weeks (IQR 4-20). Magnetic resonance imaging demonstrated contrast enhancement or abnormal signal of the affected nerve in 43% of cases. Cerebrospinal fluid analysis indicated lymphocytic pleocytosis in 59% of cases. At the onset of immune-related adverse events, 89% of patients discontinued immunotherapy, and 92% received treatment for CNP-ICI. Treatment regimens included corticosteroids in 86% of cases, intravenous immunoglobulin in 21%, and plasma exchange in 5.1%. Among the whole population, 33% achieved recovery, 52% showed clinical improvement, 16% remained stable, and 3% experienced worsening of their condition. Rechallenge with immunotherapy was significantly associated with the emergence of new immune-related Adverse Events (irAEs). CONCLUSION ICI therapy may lead to cranial nerve involvement, particularly affecting the facial nerve, typically presenting around 10 weeks after treatment initiation. While corticosteroid therapy often resulted in patient improvement, rechallenging with ICIs were associated with new irAEs.
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Affiliation(s)
- Samuel Pichon
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France.
| | - Pauline Aigrain
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - Charlotte Lacombe
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - Bruno Lemarchant
- Département de Neurologie, CRC-SEP, Université de Lille, CHU Lille, 59000, Lille, France
| | - Emmanuel Ledoult
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
- U1286-INFINITE-Institute for Translational Research in Inflammation, INSERM, Université de Lille, CHU Lille, Lille, France
| | - Vincent Koether
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
| | - Amélie Leurs
- Département de Médecine Interne et Maladies Infectieuses, CH Dunkerque, 59240, Dunkerqu, France
| | - Ghadi Zebian
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - David Launay
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
- U1286-INFINITE-Institute for Translational Research in Inflammation, INSERM, Université de Lille, CHU Lille, Lille, France
| | - Benoit Gachet
- Service de Maladies Infectieuses, CH Gustave Dron, Université de Lille, 59200, Tourcoing, France
- ULR 2694 METRICS Evaluation des Technologies de Santé et des Pratiques Médicales, CH de Tourcoing, Université de Lille, 59000, Lille, France
| | - Clémentine Levy
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
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Andoh J, Thangamathesvaran L, Arevalo JF. Exudative subretinal fluid associated with tebentafusp immunotherapy. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024:S0008-4182(24)00248-5. [PMID: 39178911 DOI: 10.1016/j.jcjo.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/23/2024] [Accepted: 08/11/2024] [Indexed: 08/26/2024]
Affiliation(s)
- Joana Andoh
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, MD, United States
| | | | - J Fernando Arevalo
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, MD, United States.
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Kiraly P, Fischer MD. RETRACTED ARTICLE: Cystoid Macular Oedema in a Patient Treated with STING Agonist and Ezabenlimab for Disseminated Melanoma. Ophthalmol Ther 2024; 13:2061. [PMID: 38467992 PMCID: PMC11178736 DOI: 10.1007/s40123-024-00911-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/15/2024] [Indexed: 03/13/2024] Open
Affiliation(s)
- Peter Kiraly
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
- Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford, United Kingdom.
| | - M Dominik Fischer
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford, United Kingdom
- Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany
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Philip AM, Fernandez-Santos CC, Dolinko AH, Massoudi Y, Valerio T, Maleki A, Foster CS. Cogan-Like Syndrome Following Nivolumab Immunotherapy for Metastatic Cutaneous Melanoma. Ocul Immunol Inflamm 2024:1-5. [PMID: 38913501 DOI: 10.1080/09273948.2024.2367661] [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: 03/01/2024] [Accepted: 06/08/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE To report a case of Cogan-Like Syndrome following treatment with nivolumab for metastatic cutaneous melanoma. METHODS A case report. RESULTS A 54-year-old female sought a second opinion from us regarding the recently diagnosed uveitis in both eyes. She had a diagnosis of metastatic cutaneous melanoma in the right arm and was undergoing treatment with nivolumab. Four weeks following the initiation of nivolumab therapy, she experienced tinnitus and bilateral sensorineural hearing loss, which was treated with oral and intratympanic steroids. While tapering the oral steroids, she developed iridocyclitis with papillitis in both eyes. This combination of vestibuloauditory symptoms and ocular inflammation was strikingly reminiscent of Cogan's syndrome. Because of the timing in relation to the nivolumab therapy and the steroid responsiveness of her presentation, this was speculated to be due to immune overactivation from the nivolumab. Given her complex condition, which involved toxicity and multiple metastases, the patient was advised to consider either topical and/or local corticosteroids or intravenous immunoglobulin. The patient chose to persist with corticosteroid therapy. CONCLUSION Nivolumab could potentially be linked to an immune-related condition resembling Cogan syndrome. In cases involving patients with a complex condition necessitating nivolumab treatment, the use of topical and/or local corticosteroids or intravenous immunoglobulin, might constitute the sole viable treatment options.
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Affiliation(s)
- Andrew M Philip
- Ophthalmology, Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - Carla C Fernandez-Santos
- Ophthalmology, Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - Andrew H Dolinko
- Ophthalmology, Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - Yasmin Massoudi
- Ophthalmology, Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - Tate Valerio
- Ophthalmology, Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - Arash Maleki
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
- Department of Ophthalmology, University of Florida, Gainesville, Florida, USA
| | - C Stephen Foster
- Ophthalmology, Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Xiang X, Lin W, Guan X, Zhou B, Yuan Y, Silva D, Wang Y. Corneal ulcer development due to sintilimab-anlotinib combination therapy-induced dry eye: a case report. Transl Cancer Res 2024; 13:2571-2579. [PMID: 38881937 PMCID: PMC11170519 DOI: 10.21037/tcr-23-1952] [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: 10/21/2023] [Accepted: 04/07/2024] [Indexed: 06/18/2024]
Abstract
Background Programmed cell death-1 (PD-1) inhibitors and anti-angiogenic drugs have become a hotspot in research of anti-tumor programs; however, they can also cause some rare drug-related adverse reactions. Immune checkpoint inhibitors (ICIs) cause adverse reactions in the body, collectively known as immune-related adverse events (irAEs). Ocular side effects can occur in both targeted and immunotherapy patients, including dry eye, blurred vision, uveitis, conjunctivitis, retinopathy, or thyroid eye disease. To our knowledge, this is the first case report describing corneal ulcers secondary to dry eye in a patient treated with the combination of PD-1 inhibitor sintilimab and multi-targeted receptor tyrosine kinase inhibitor (TKI) anlotinib. Case Description A 65-year-old woman with non-small cell lung cancer (NSCLC) and bone metastases, without pre-existing ocular conditions, experienced mild dry eye symptoms 1 month following treatment with sintilimab (200 mg q3w) in combination with anlotinib (12 mg q3w). Unrelieved dry eye symptoms occurred after the third cycle of chemotherapy, and she was diagnosed with dry eye syndrome. Subsequently, she received corneal protective lens, sodium hyaluronate eye drops, and prednisone treatment. Her corneal epithelial damage did not improve significantly, and within the following 2 months, her vision decreased in both eyes and progressed to bilateral corneal ulcers. Oral administration of sintilimab and anlotinib was interrupted, and treatments such as corticosteroids, anti-inflammatory drugs, and corneal repair were administered; however, both eyes presented with corneal subepithelial defect and corneal scarring. Due to a shortage of donors, no corneal transplantation surgery could be performed. Conclusions The development of corneal epithelial disorders in patients receiving target therapy and immunotherapy may not be reversed by reducing its dose. Although the condition is controlled with the use of glucocorticoids, some eye side effects cannot be cured. The timely detection and intervention of adverse effects of anti-tumor drugs by oncologists and ophthalmologists is critical for rational prescription. Ophthalmologists should be aware of eye side effects in patients using immunotherapy to ensure appropriate treatment and minimize potential eye complications such as dry eye, conjunctivitis, etc.
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Affiliation(s)
- Xiaolan Xiang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Waner Lin
- Department of Ophthalmology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaoying Guan
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bingqian Zhou
- Department of Ophthalmology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuan Yuan
- Department of Ophthalmology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Diana Silva
- Ophthalmology Department, Hospital Prof. Dr. Fernando Fonseca E.P.E., Lisbon, Portugal
| | - Yan Wang
- Department of Ophthalmology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Chen A, Chwalisz BK. Update on Neuro-ophthalmic Manifestations of Immune Checkpoint Inhibitors. Curr Neurol Neurosci Rep 2024; 24:113-122. [PMID: 38498093 DOI: 10.1007/s11910-024-01336-z] [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] [Accepted: 02/25/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI) use has been on the rise for treatment of many different malignancies. Subsequently, more has been learned about immune-related adverse events (irAEs) that occur up to 12 months after treatment. This review summarizes the latest findings and management of neuro-ophthalmic associated irAEs. RECENT FINDINGS irAEs can affect the afferent and efferent neuro-ophthalmic pathways, thereby targeting central and peripheral nervous systems. As more cases are being reported, it is becoming apparent that neuro-ophthalmic irAEs often present with atypical features when compared to their spontaneous autoimmune counterparts. These neuro-ophthalmic presentations can also be signs of a more extensive inflammatory process that spans other organ systems, such as myopathies, endocrinopathies, and paraneoplastic syndromes. Awareness of neuro-ophthalmic irAEs and their atypical presentations can lead to early detection, termination of ICI treatment, and immunosuppressant therapy initiation.
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Affiliation(s)
- Amalie Chen
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Bart K Chwalisz
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, MA, USA.
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Fernández Jiménez-Ortiz H, Maroto Rodríguez B, Lapuente Monjas R, Sampedro Yáñez R, Sánchez Santos I, Toledano Fernández N. Iatrogenic affectation of ocular motility by immune checkpoint inhibitors. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2024; 99:158-164. [PMID: 38013131 DOI: 10.1016/j.oftale.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
Cancer therapy relies on new antitumoral drugs called immune checkpoint inhibitors (ICI), which produce long-lasting anti-tumor responses and lengthen survival, but cause autoimmune-type toxicity. The clinical characteristics induced by ICI are not well characterized to date and careful collection of clinical data is required to accurately define its safety profile. We conducted a literature search in the main clinical search engines to identify pharmacological ocular iatrogenic events of ICIs related to ocular motility. Four systematic reviews were found that included this type of ocular iatrogenesis as well as numerous isolated case reports. Reported adverse effects include: oculomotor paresis, optic neuropathy, optic atrophy, myastheniform syndromes, thyroid pseudo-orbitopathy, orbital apex syndrome, and hypophysitis. Most were managed without interruption or with partial interruption of cancer treatment. Aggressive systemic treatments were required for adequate management of ocular iatrogenic events. It is essential that the ophthalmologist become familiar with the new ICI oncological treatments, capable of causing severe and disabling motilidad ocular iatrogenesis for the patient. The communication of adverse effects and the report of the treatments used can help the most appropriate management of these patients. Research should be oriented towards complex differential diagnosis and to optimize decisions on cancer treatments.
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Affiliation(s)
| | - B Maroto Rodríguez
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - R Lapuente Monjas
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain.
| | - R Sampedro Yáñez
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | | | - N Toledano Fernández
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
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Zhang H, Houadj L, Wu KY, Tran SD. Diagnosing and Managing Uveitis Associated with Immune Checkpoint Inhibitors: A Review. Diagnostics (Basel) 2024; 14:336. [PMID: 38337852 PMCID: PMC10855398 DOI: 10.3390/diagnostics14030336] [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: 01/02/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
This review aims to provide an understanding of the diagnostic and therapeutic challenges of uveitis associated with immune checkpoint inhibitors (ICI). In the wake of these molecules being increasingly employed as a treatment against different cancers, cases of uveitis post-ICI therapy have also been increasingly reported in the literature, warranting an extensive exploration of the clinical presentations, risk factors, and pathophysiological mechanisms of ICI-induced uveitis. This review further provides an understanding of the association between ICIs and uveitis, and assesses the efficacy of current diagnostic tools, underscoring the need for advanced techniques to enable early detection and accurate assessment. Further, it investigates the therapeutic strategies for ICI-related uveitis, weighing the benefits and limitations of existing treatment regimens, and discussing current challenges and emerging therapies in the context of their potential efficacy and side effects. Through an overview of the short-term and long-term outcomes, this article suggests recommendations and emphasizes the importance of multidisciplinary collaboration between ophthalmologists and oncologists. Finally, the review highlights promising avenues for future research and development in the field, potentially informing transformative approaches in the ocular assessment of patients under immunotherapy and the management of uveitis following ICI therapy.
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Affiliation(s)
- Huixin Zhang
- Faculty of Medicine, Laval University, Quebec, QC G1V 0A6, Canada;
| | - Lysa Houadj
- Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada;
| | - Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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Qian Y, Eppley S, Baer D, Melles RB. Characteristics of Ocular Inflammatory Side Effects Associated with Immune Checkpoint Inhibitors in a Northern California Population. Ocul Immunol Inflamm 2024; 32:98-104. [PMID: 36637986 DOI: 10.1080/09273948.2022.2159447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 12/12/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE To characterize the ocular inflammatory side effects associated with immune checkpoint inhibitor (CPI) treatment in a Northern California population. DESIGN Retrospective case series. PARTICIPANTS Patients receiving CPI within an integrated healthcare delivery system. METHODS All patients within Kaiser Permanente Northern California receiving CPI between January 1, 2012 and November 1, 2018 were identified. Medical records of those seen in the ophthalmology clinic at least once were retrospectively reviewed. MAIN OUTCOME MEASURES Type and duration of ocular inflammation, indication for and exposure to CPI, time from exposure to diagnosis of ocular inflammation. RESULTS 31 cases of ocular inflammation were identified in 5061 patients (0.61%) receiving CPI. Mean ± SD age was 67 ± 11.9 (range 38-89). Mean time from exposure to diagnosis was 6.8 ± 5.5 months (range 0.5-17). 87% of cases were bilateral, and 43% of cases were chronic. Average ophthalmology follow-up was 16 ± 18 months (range 0-71). 16/31 (52%) had anterior uveitis, 7/31 (23%) had serous retinal detachment or panuveitis resembling Vogt-Koyanagi-Harada syndrome, 4/31 (13%) had papillitis, and 6/31 (19%) had diplopia or ocular motility defect. There was one case each (3.2%) of melanoma associated retinopathy, corneal edema, granulomatous lacrimal gland enlargement, and choroidal neovascularization. CONCLUSIONS Ocular inflammation is a rare immune associated side effect of CPI treatment, the most common manifestation of which is anterior uveitis.
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Affiliation(s)
- Ying Qian
- Department of Ophthalmology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Sarah Eppley
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California, USA
| | - David Baer
- Department of Oncology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Ronald B Melles
- Department of Ophthalmology, Kaiser Permanente Redwood City Medical Center, Redwood City, California, USA
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Philip AM, Anesi SD, Foster CS, Chang P. Ocular Inflammatory Complications of Treatment for Metastatic Melanoma. Ocul Immunol Inflamm 2023; 31:1669-1673. [PMID: 35914291 DOI: 10.1080/09273948.2022.2098147] [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: 10/08/2021] [Accepted: 06/20/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE To characterize various ocular inflammatory complications arising from metastatic cutaneous melanoma therapies and their management. METHODS Retrospective case series of patients who were referred to a tertiary uveitis practice for ophthalmic exam All patients received targeted metastatic cutaneous melanoma treatment, including BRAF/MEK inhibitors and various immunotherapies. RESULTS 109 patients were identified, with 43 (39.4%) having 65 definitive instances of OIAE. Sixteen different OIAE were identified. Ipilimumab monotherapy and ipilimumab/nivolumab combination therapy were most commonly associated. Anterior uveitis was the most common OIAE (18/65, 27.7%). Thirty patients (69.8%) were managed with observation or topical steroid therapy. Only 4 patients required further therapies for OIAE, with one patient not attaining resolution. CONCLUSIONS AND RELEVANCE While a broad range of OIAE was identified, most were not vision-threatening and did not require discontinuation of the associated therapy.
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Affiliation(s)
- Andrew M Philip
- The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
| | - Stephen D Anesi
- The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
| | - C Stephen Foster
- The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Chang
- The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
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Kazemzadeh K, Behrouzieh S, Rezaei N. Shedding light on the side effects of immunotherapies used for leukemia: an updated review of the literature. Expert Rev Anticancer Ther 2023; 23:1193-1204. [PMID: 37812581 DOI: 10.1080/14737140.2023.2267760] [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: 06/26/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Leukemia is an abnormal clonal development of leukemic cells originating from the bone marrow, which is widely known for its significant prevalence and mortality rate. Chemotherapy, surgery, radiation, and combination therapies have been its routine therapeutic methods; however, the advent of cancer immunotherapy is known as revolutionary for its higher efficacy and lesser toxicity. AREAS COVERED Immunotherapy boosts the body's immune system by using components from other living organisms. Although immunotherapy seems to be safer than chemotherapy, many studies have noticed different immune-related side effects in various body systems (e.g. cardiovascular, neurologic) which we have reviewed in this investigation as the main goal. We tried to describe immunotherapy-related side effects in human body systems in detail. EXPERT OPINION Being aware of these side effects leads to better clinical decision-making for each individual, and a one-step-ahead management in case of occurrence. We also briefly discussed the role of immunotherapy in treating leukemia as one of the most prevalent cancers in children and tried to emphasize that it is crucial to monitor adverse events as they may remain obscure until adolescence.
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Affiliation(s)
- Kimia Kazemzadeh
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Network of Neurosurgery and Artificial Intelligence (NONAI), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Sadra Behrouzieh
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Neurosurgery and Artificial Intelligence (NONAI), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Daetwyler E, Zippelius A, Meyer P, Läubli H. Pembrolizumab-induced optic neuropathy - a case report. Front Immunol 2023; 14:1171981. [PMID: 37228591 PMCID: PMC10203429 DOI: 10.3389/fimmu.2023.1171981] [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: 02/22/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Background Immune checkpoint inhibitor (ICI) treatment has become important for treating various cancer types, including Hodgkin's lymphoma. However, ICI can overstimulate the immune system, leading to a broad range of immunological side effects, known as immune-related adverse events (irAEs). Here, we report a case of optic neuropathy caused by pembrolizumab. Case presentation A patient with Hodgkin's lymphoma received pembrolizumab every three weeks. Twelve days after the sixth cycle of pembrolizumab, the patient was admitted to the emergency department with blurred vision, visual field impairment and altered color perception affecting the right eye. The diagnosis of immune-related optic neuropathy was established. Pembrolizumab was stopped permanently and high-dose steroid treatment was immediately started. This emergency treatment led to a satisfactory binocular vision and an improvement of visual acuity testing results. After another 7 months, the left eye was affected with the same symptoms. At this time, only an extended immunosuppressive therapy consisting of high-dose steroid treatment, plasmapheresis, immunoglobulin treatment, retrobulbar injection of steroids and mycophenolate mofetil, successfully reduced the symptoms. Conclusions This case highlights the need for prompt recognition and treatment of rare irAEs, such as optic neuropathy. Urgent treatment with initial high-dose steroid treatment is required to avoid persistent loss of visual acuity. Options for further treatment are mainly based on small case series and case reports. In our case, a retrobulbar injection of steroids in combination with mycophenolate mofetil showed significant success in treating steroid-refractory optic neuropathy.
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Affiliation(s)
- Eveline Daetwyler
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Alfred Zippelius
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Peter Meyer
- Eye Clinic, University Hospital Basel, Basel, Switzerland
| | - Heinz Läubli
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
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15
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Ng CC, Ng JC, Johnson RN, McDonald HR, Agarwal A. NIVOLUMAB-INDUCED HARADA-LIKE UVEITIS WITH BACILLARY DETACHMENT MIMICKING CHOROIDAL METASTASIS. Retin Cases Brief Rep 2023; 17:233-238. [PMID: 34027908 DOI: 10.1097/icb.0000000000001165] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe a patient with metastatic clear cell renal cell carcinoma in remission on maintenance nivolumab therapy who developed late-onset ocular toxicity manifesting as creamy chorioretinal lesions with exudative retinal detachment concerning for choroidal metastasis. METHOD Case report. Main outcome measures include ophthalmoscopic examination, fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography, and B-scan ultrasonography. RESULTS A 49-year-old woman with a medical history of metastatic clear cell renal cell carcinoma in remission for two years after immunotherapy with four cycles of ipilimumab and nivolumab followed by maintenance nivolumab infusions developed lesions concerning for choroidal metastases in her right eye. Optical coherence tomography of the lesions revealed a bacillary layer detachment containing possible fibrinous exudate organized into layers and underlying choroidal thickening with chorioretinal folds. Later, choroidal thickening and chorioretinal folds also occurred in the left eye. Given that pan imaging detected no metastasis and the posterior segment abnormalities resolved after cessation of nivolumab and treatment with systemic corticosteroids, the patient was diagnosed with nivolumab-induced Vogt-Koyanagi-Harada-like uveitis. CONCLUSION This case expands on the clinical spectrum of nivolumab-induced Vogt-Koyanagi-Harada-like uveitis, a condition that can also present with bacillary layer detachment mimicking an early choroidal metastasis, manifest asymmetrically in each eye, and develop after long-standing treatment.
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Affiliation(s)
- Caleb C Ng
- West Coast Retina Medical Group, San Francisco, California; and
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
| | - Joshua C Ng
- West Coast Retina Medical Group, San Francisco, California; and
| | - Robert N Johnson
- West Coast Retina Medical Group, San Francisco, California; and
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
| | - H Richard McDonald
- West Coast Retina Medical Group, San Francisco, California; and
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
| | - Anita Agarwal
- West Coast Retina Medical Group, San Francisco, California; and
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
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16
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Tieger MG, Eliott D, Cakir B, Dahrouj M. Checkpoint Inhibitor-Associated Vogt-Koyanagi-Harada Disease Presenting 3 Months Following Discontinuation of Nivolumab. Ophthalmic Surg Lasers Imaging Retina 2023; 54:183-187. [PMID: 36944065 DOI: 10.3928/23258160-20230221-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The use of checkpoint inhibitors has been associated with multiple ocular and orbital complications including Vogt-Koyanagi-Harada disease. In the current case, a 55-year-old man presented with visual changes 3 months following discontinuation of nivolumab for metastatic renal cell carcinoma. This is the second report of delayed presentation following discontinuation of a checkpoint inhibitor and the only case not associated with an alternative targeted therapy at the time of presentation. This article highlights a unique presentation of delayed checkpoint inhibitor-associated Vogt-Koyanagi-Harada and summarizes the reported cases. [Ophthalmic Surg Lasers Imaging Retina 2023;54(3):183-187.].
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17
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Martens A, Schauwvlieghe PP, Madoe A, Casteels I, Aspeslagh S. Ocular adverse events associated with immune checkpoint inhibitors, a scoping review. J Ophthalmic Inflamm Infect 2023; 13:5. [PMID: 36811715 PMCID: PMC9947214 DOI: 10.1186/s12348-022-00321-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/11/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have become an important part of the treatment of multiple cancers, especially for advanced melanoma and non-small cell lung cancer. Some tumors are capable of escaping immunosurveillance by stimulating checkpoints on T-cells. ICIs prevent activation of these checkpoints and thereby stimulate the immune system and indirectly the anti-tumor response. However, the use of ICIs is associated with various adverse events. Ocular side effects are rare but may have a major impact on the quality of life of the patient. METHODS A comprehensive literature search of the medical databases Web of Science, Embase and PubMed was performed. Articles that provided a comprehensive description of a case report containing 1) cancer patient(s) treated with (a combination of) immune checkpoint inhibitors, and 2) assessed occurrence of ocular adverse events, were included. A total of 290 case reports were included. RESULTS Melanoma (n = 179; 61.7%) and lung cancer (n = 56; 19.3%) were the most frequent reported malignancies. The primary used ICIs were nivolumab (n = 123; 42.5%) and ipilimumab (n = 116; 40.0%). Uveitis was most the common adverse event (n = 134; 46.2%) and mainly related to melanoma. Neuro-ophthalmic disorders, including myasthenia gravis and cranial nerve disorders, were the second most common adverse events (n = 71; 24.5%), mainly related to lung cancer. Adverse events affecting the orbit and the cornea were reported in 33 (11.4%) and 30 cases (10.3%) respectively. Adverse events concerning the retina were reported in 26 cases (9.0%). CONCLUSION The aim of this paper is to provide an overview of all reported ocular adverse events related to the use of ICIs. The insights retrieved from this review might contribute to a better understanding of the underlying mechanisms of these ocular adverse events. Particularly, the difference between actual immune-related adverse events and paraneoplastic syndromes might be relevant. These findings might be of great value in establishing guidelines on how to manage ocular adverse events related to ICIs.
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Affiliation(s)
- A. Martens
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - P. P. Schauwvlieghe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - A. Madoe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - I. Casteels
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - S. Aspeslagh
- grid.411326.30000 0004 0626 3362Department of Medical Oncology, University Hospital Brussels, Brussels, Belgium
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18
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Pietris J, Santhosh S, Ferdinando Cirocco G, Lam A, Bacchi S, Tan Y, Gupta AK, Kovoor JG, Chan W. Immune Checkpoint Inhibitors and Optic Neuropathy: A Systematic Review. Semin Ophthalmol 2023:1-12. [PMID: 36683270 DOI: 10.1080/08820538.2023.2168494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors are a class of monoclonal antibodies that are used as a mainstay of immunotherapy for multiple solid organ malignancies. With the recent increase in popularity of these agents, immune-related adverse events including optic neuropathy are becoming more frequently reported. This review aims to explore the association between immune checkpoint inhibitors and optic neuropathy through analysis of incidence, clinical features, investigations, treatment, and patient outcomes. METHOD A systematic search of the databases PubMed/MEDLINE, Embase, and CENTRAL was performed from inception to September 2022. Data collection and risk of bias analysis was subsequently conducted in accordance with the PRISMA guidelines. RESULTS Eleven articles fulfilled the inclusion criteria. The results showed an increased incidence of optic neuropathy among patients receiving immune checkpoint inhibitor therapy compared to the general population. Presentation with painless reduced visual acuity and optic disc swelling was most common. Investigation findings were poorly documented. The only two patients who achieved full resolution of symptoms were treated with oral prednisolone. CONCLUSION There is a strong association between immune checkpoint inhibitor therapy and development of optic neuropathy. Although it remains uncommon, the incidence of optic neuropathy in this population exceeds that of the general population. Future research is needed to further characterise the risk profiles of patients who are most likely to develop ICI-associated optic neuropathy, and treatment pathways for these patients.
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Affiliation(s)
- James Pietris
- Faculty of Medicine, University of Queensland, Herston, Australia.,Princess Alexandra Hospital, Woolloongabba, Australia
| | - Sanjana Santhosh
- Faculty of Medicine, University of Adelaide, Adelaide, Australia
| | | | - Antoinette Lam
- Faculty of Medicine, University of Adelaide, Adelaide, Australia.,Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
| | - Stephen Bacchi
- Faculty of Medicine, University of Adelaide, Adelaide, Australia.,Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia.,Flinders University, Bedford Park, Australia
| | - Yiran Tan
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
| | - Aashray K Gupta
- Faculty of Medicine, University of Adelaide, Adelaide, Australia.,Gold Coast University Hospital, Southport, Australia
| | - Joshua G Kovoor
- Faculty of Medicine, University of Adelaide, Adelaide, Australia.,Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
| | - WengOnn Chan
- Faculty of Medicine, University of Adelaide, Adelaide, Australia.,Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
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Cho WH, Chiang WY. Case Report: Serial changes of ocular complications related to immune checkpoint inhibitors pembrolizumab and nivolumab. FRONTIERS IN OPHTHALMOLOGY 2023; 2:1021574. [PMID: 38983552 PMCID: PMC11182155 DOI: 10.3389/fopht.2022.1021574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/07/2022] [Indexed: 07/11/2024]
Abstract
Background To demonstrate the rare ocular side effects in a patient receiving pembrolizumab and nivolumab for metastatic ovarian cancer. Case presentation A 37-year-old woman with recurrent metastatic ovarian cancer presented with blurred vision and photophobia after receiving pembrolizumab. Ocular findings were bilateral anterior chamber reactions, iris cysts, and macular flecks. Optical coherence tomography (OCT) indicated retinal pigment epithelium (RPE) and ellipsoid-band disruption. Her symptoms subsided with topical steroids but fundal appearance persisted despite cessation of immunotherapies. Similar episodes attacked again with multiple exudative subretinal fluid (SRF) developed after she received pembrolizumab and nivolumab. Steroids could cease anterior chamber reactions while SRF only subsided after discontinuation of immunotherapy. Extensive RPE and ellipsoid-band disruption remained without vision improvements. Conclusions We report a rare case of uveitis and retinopathy after immunotherapies with sequent pembrolizumab and nivolumab. A serial change of the maculopathy is demonstrated. Possible ocular toxicities during the treatment course should be considered, and the benefits of continuing the immunotherapy must be weighed against the risks.
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Affiliation(s)
- Wan-Hua Cho
- Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
| | - Wei-Yu Chiang
- Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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20
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Gan L, Chen H, Liu X, Zhang L. Ophthalmic immune-related adverse events associated with immune checkpoint inhibitors. Front Immunol 2023; 14:1130238. [PMID: 37033964 PMCID: PMC10076523 DOI: 10.3389/fimmu.2023.1130238] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/15/2023] [Indexed: 04/11/2023] Open
Abstract
Purpose To investigate the incidence of immune-related adverse events (irAEs) of immune checkpoint inhibitor (ICI) therapy and to report the clinical features, management, and outcomes of ophthalmic irAEs. Methods We retrospectively reviewed the medical records of patients who received ICI therapy from January 2016 to September 2022 at Peking Union Medical College Hospital and analyzed the incidence of systemic and ophthalmic adverse effects of this therapy. Results Of 962 patients, 248 (25.8%) experienced irAEs. The first-year incidences of total irAEs and ophthalmic irAEs were 23.5% and 1.1%. The most common ICI received by the patients was pembrolizumab (373; 38.8%). Nearly half of the patients (477; 49.6%) had lung cancer. Combination therapy was associated with an increased incidence of irAEs without statistical significance. Patients with lung cancer presented with an increased incidence of total irAEs (p = 0.003) and ophthalmic irAEs (p = 0.032). Eleven patients had ophthalmic manifestations, including ophthalmoplegia (6/11), conjunctivitis (3/11), reactive cutaneous capillary endothelial proliferation (RCCEP) (1/11), and orbital inflammation (1/11). Eight patients had concomitant extra-ophthalmic irAEs. Furthermore, ICIs were discontinued in nine patients, and most ophthalmic manifestations were well controlled with topical and systemic steroids. Ten patients were treated with intravenous or oral steroids. However, cancer progression occurred in five out of eleven patients after the interruption of ICIs. Conclusion IrAEs are correlated with ICI regimens and underlying neoplasia. In our Chinese cohort, patients have a higher risk of ophthalmoplegia than uveitis. Early recognition and multidisciplinary consultation are crucial for optimal treatment of ophthalmic irAEs.
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Affiliation(s)
- Linyang Gan
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huan Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaowei Liu
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Xiaowei Liu, ; Li Zhang,
| | - Li Zhang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Xiaowei Liu, ; Li Zhang,
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Khalatbari H, Shulkin BL, Parisi MT. Emerging Trends in Radionuclide Imaging of Infection and Inflammation in Pediatrics: Focus on FDG PET/CT and Immune Reactivity. Semin Nucl Med 2023; 53:18-36. [PMID: 36307254 DOI: 10.1053/j.semnuclmed.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
The most common indication for 18F-FDG PET/CT is tumor imaging, which may be performed for initial diagnosis, staging, therapeutic response monitoring, surveillance, or suspected recurrence. In the routine practice of pediatric nuclear medicine, most infectious, inflammatory, and autoimmune processes that are detected on 18F-FDG PET/CT imaging - except for imaging in fever or inflammation of unknown origin - are coincidental and not the main indication for image acquisition. However, interpreting these "coincidental" findings is of utmost importance to avoid erroneously attributing these findings to a neoplastic process. We review the recent literature on fever of unknown origin as well as inflammation of unknown origin in pediatrics and then focus on the 18F FDG PET/CT imaging findings seen in two specific entities with increased immune reactivity: hemophagocytic lymphohistiocytosis syndrome and the immune-related adverse events associated with checkpoint inhibitors. We will subsequently close with two sections highlighting related topics and relevant references for further reading.
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Affiliation(s)
- Hedieh Khalatbari
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Barry L Shulkin
- Department of Diagnostic Radiology, St. Jude Children's Research Hospital, Memphis, TN.
| | - Marguerite T Parisi
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
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22
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Alberti P, Salvalaggio A, Argyriou AA, Bruna J, Visentin A, Cavaletti G, Briani C. Neurological Complications of Conventional and Novel Anticancer Treatments. Cancers (Basel) 2022; 14:cancers14246088. [PMID: 36551575 PMCID: PMC9776739 DOI: 10.3390/cancers14246088] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Various neurological complications, affecting both the central and peripheral nervous system, can frequently be experienced by cancer survivors after exposure to conventional chemotherapy, but also to modern immunotherapy. In this review, we provide an overview of the most well-known adverse events related to chemotherapy, with a focus on chemotherapy induced peripheral neurotoxicity, but we also address some emerging novel clinical entities related to cancer treatment, including chemotherapy-related cognitive impairment and immune-mediated adverse events. Unfortunately, efficacious curative or preventive treatment for all these neurological complications is still lacking. We provide a description of the possible mechanisms involved to drive future drug discovery in this field, both for symptomatic treatment and neuroprotection.
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Affiliation(s)
- Paola Alberti
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
- NeuroMI (Milan Center for Neuroscience), 20126 Milan, Italy
| | | | - Andreas A. Argyriou
- Neurology Department, Agios Andreas State General Hospital of Patras, 26335 Patras, Greece
| | - Jordi Bruna
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO Hospitalet, Bellvitge Institute for Biomedical Research (IDIBELL), 08908 Barcelona, Spain
| | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35131 Padova, Italy
| | - Guido Cavaletti
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Chiara Briani
- Neurology Unit, Department of Neurosciences, University of Padova, 35131 Padova, Italy
- Correspondence:
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Su Y, Li G, Xu J, Zheng J, Jiao J, Zhang J, Gu X, Cai Z, Luo H, Li Z, Han S. Immune-related keratitis is a rare complication associated with nivolumab treatment in a patient with advanced colorectal cancer: A case report. Front Oncol 2022; 12:1021713. [PMID: 36457511 PMCID: PMC9706189 DOI: 10.3389/fonc.2022.1021713] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/13/2022] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Immunotherapy has been widely used to treat Colorectal cancer but has also observe some immune-related adverse effects. With proper treatment, most irAE can be solved and the effect of immunotherapy will not be affected by temporary immunosuppression. However, there are few reports about corneal irAE, and the current understanding of irAE is incomplete. Here we report a metastatic colorectal cancer case of immune-related keratitis caused by nivolumab and to explore the occurrence of immune-related keratitis. CASE DESCRIPTION Here we report the case of a 49-year-old man with mCRC who had no previous ocular disease but developed immune-related ulcerative keratitis after treatment with nivolumab. We summarize a large amount of literature to discuss the mechanism of immune-related keratitis. In addition, we conclude a method that may be used to detect the occurrence of immune keratitis, by monitoring MMPs and maspin in patients treated with nivolumab. We believe immune-related keratitis may be a rare complication of nivolumab in the treatment of mCRC. The effect of simple anti-infective therapy and repair-promoting drugs was not obvious, but the effect of glucocorticoid combined with autologous serum was significant. CONCLUSION The mechanism of immune-related keratitis is that nivolumab destroys the immune microenvironment and ACAID, and affects corneal healing. Patients who use nivolumab can prevent immune keratitis by testing MMPs and maspin. The occurrence of immune keratitis may be a good indicator of the efficacy of ICI, and further study can be done in the follow-up.
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Affiliation(s)
- Yuqi Su
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Guoquan Li
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Jiaxin Xu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jiale Zheng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jiapeng Jiao
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jianhui Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Xiaokang Gu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Zhai Cai
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hongyu Luo
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Zhou Li
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shuai Han
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Immune-Related Uncommon Adverse Events in Patients with Cancer Treated with Immunotherapy. Diagnostics (Basel) 2022; 12:diagnostics12092091. [PMID: 36140493 PMCID: PMC9498261 DOI: 10.3390/diagnostics12092091] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/06/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Immunotherapy has dramatically changed the therapeutic landscape of oncology, and has become standard of care in multiple cancer types in front or late lines of therapy, with some longstanding responses and outstanding results. Notwithstanding, its use has brought a totally unique spectrum of adverse events, characterized by a myriad of diverse manifestations affecting nearly every organ and system of the body, including the endocrine, nervous, cardiac, respiratory and gastrointestinal systems. Uncommon adverse events, defined as those occurring in less than 1% of patients, comprise an even more heterogeneous group of diseases that are being seen more recurrently as the use of immune check-point inhibitors increases and indications spread in different tumor types and stages. Here, we comprehensively review some uncommon, but exceedingly important, immune-related adverse events, with special emphasis in the clinical approach and diagnostic workup, aiming to reunite the evidence published previously, allowing an increase in awareness and knowledge from all specialists implicated in the diagnosis, treatment, and care of cancer patients treated with immunotherapy.
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Ocular Inflammation Induced by Immune Checkpoint Inhibitors. J Clin Med 2022; 11:jcm11174993. [PMID: 36078923 PMCID: PMC9456546 DOI: 10.3390/jcm11174993] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Ocular immunotherapy-related adverse events (IRAEs), although rare, can be sight-threatening. Our objective was to analyze ocular IRAEs diagnosed in France from the marketing of immune checkpoint inhibitors (ICPIs) until June 2021 and to review the literature. We collected the cases of 28 patients (36 ocular IRAEs), occurring after an average of 17 weeks (±19). Forty-six percent of patients were treated for metastatic melanoma. Anti-PD1 agents were responsible for 57% of the IRAEs. Anterior uveitis was the most common (44%), followed by panuveitis (28%). Of 25 uveitis cases, 80% were bilateral and 60% were granulomatous. We found one case with complete Vogt-Koyanagi–Harada syndrome and one case of birdshot retinochoroidopathy. The other IRAEs were eight ocular surface disorders, one optic neuropathy, and one inflammatory orbitopathy. Seventy percent of the IRAEs were grade 3 according to the common terminology of AEs. ICPIs were discontinued in 60% of patients and 50% received local corticosteroids alone. The literature review included 230 uveitis cases, of which 7% were granulomatous. The distributions of ICPIs, cancer, and type of uveitis were similar to our cohort. Ocular IRAEs appeared to be easily controlled by local or systemic corticosteroids and did not require routine discontinuation of ICPIs. Further work is still warranted to define the optimal management of ocular IRAEs.
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Bilateral diffuse uveal melanocytic proliferation (BDUMP) as ocular toxicity from durvalumab in advanced renal carcinoma. Eur J Cancer 2022; 171:10-12. [PMID: 35709599 DOI: 10.1016/j.ejca.2022.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/27/2022] [Indexed: 11/22/2022]
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Garweg JG. [Induction of Uveitis by Immune-Oncologic Therapies, Namely Checkpoint Inhibitors]. Klin Monbl Augenheilkd 2022; 239:575-581. [PMID: 35472809 DOI: 10.1055/a-1766-6119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The recently introduced tumor therapies including immune checkpoint and BRAF/MEK inhibitors (ICI) have substantially contributed to survival and quality of life of the affected patients, but are associated with class-specific, non-toxic immune-related side effects including uveitis. This narrative review focusses to summarize the immune-related adverse event profile associated with the use of ICI. METHODS A literature search in PubMed, the publication database of the National Institute of Health in the USA (https://www.ncbi.nlm.nih.gov/pubmed) used the search terms "uveitis" AND "drug-induced" AND/OR "immune checkpoint inhibitor". All articles published in the last five years and the for the purpose of this review relevant cross references were evaluated. RESULTS A class-specific phenomenon of ICI and BRAF/MEK inhibitors is their capability to induce systemic and ocular autoimmunity. Ocular side effects are observed in up to 3% of patients and should be differentiated from toxic side effects, since this is not dose-dependent. Melanoma as underlying disease and Pembrolizumab as ICI significantly increase the risk. If timely recognized, systemic treatment with corticosteroids allows to preserve vision without cessation of the tumor treatment in more than 90% of these potentially life-threatening instances. CONCLUSION Given their impact onto the survival of cancer and namely melanoma patients, ICI and BRAF/MEK inhibitors are increasingly used alone and in combination, which enhances their inherent risk of developing drug-induced ocular autoimmunity. Favorable functional outcomes are closely linked to early recognition and aggressive treatment of these complications considering the fact that these immune-related adverse events affect multiple organ systems and have an untreated lethality of up to 3%.
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Affiliation(s)
- Justus G Garweg
- Berner Augenklinik am Lindenhofspital, Swiss Eye Institute, Universität Bern, Bern, Schweiz
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Various clinical presentations of uveitis associated with durvalumab treatment. Radiol Oncol 2022; 56:129-137. [PMID: 35412706 PMCID: PMC9122297 DOI: 10.2478/raon-2022-0007] [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: 11/24/2021] [Accepted: 01/10/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) are becoming increasingly common in treating several cancer types. Durvalumab is a human IgG1 monoclonal antibody that blocks PD-L1 binding to PD-1 and CD80 and has recently been approved for the treatment of extensive-stage small-cell lung cancer (ES-SCLC) and locally advanced unresectable (NSCLC). The present review aimed to analyse immune-mediated uveitis, secondary to durvalumab treatment, through a review of the literature and a presentation of two clinical cases. PATIENTS AND METHODS A literature review using PubMed search was conducted to identify cases of uveitis secondary to durvalumab and cases of uveitis with optic disc oedema secondary to ICI use that were reported prior to November 14, 2021. Additionally, we report two cases of uveitis consequent on durvalumab treatment. RESULTS Five cases of uveitis secondary to durvalumab use were identified in the literature. Anterior, posterior uveitis and vasculitis were reported. Additionally, we present a case of bilateral intermediate uveitis with bilateral optic disc oedema and a case of bilateral posterior uveitis. Our further search revealed 12 cases of uveitis with optic disc oedema secondary to ICI use, with the majority of cases reported secondary to PD-1 inhibitors. CONCLUSIONS Rarely reported, uveitis secondary to durvalumab can present various clinical pictures and requires a thorough diagnostic workup. Once the diagnosis is established, treatment, commonly with a local or systemic corticosteroid, should be adapted to the severity of the inflammation.
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Poto R, Troiani T, Criscuolo G, Marone G, Ciardiello F, Tocchetti CG, Varricchi G. Holistic Approach to Immune Checkpoint Inhibitor-Related Adverse Events. Front Immunol 2022; 13:804597. [PMID: 35432346 PMCID: PMC9005797 DOI: 10.3389/fimmu.2022.804597] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) block inhibitory molecules, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), or its ligand, programmed cell death protein ligand 1 (PD-L1) and enhance antitumor T-cell activity. ICIs provide clinical benefits in a percentage of patients with advanced cancers, but they are usually associated with a remarkable spectrum of immune-related adverse events (irAEs) (e.g., rash, colitis, hepatitis, pneumonitis, endocrine, cardiac and musculoskeletal dysfunctions). Particularly patients on combination therapy (e.g., anti-CTLA-4 plus anti-PD-1/PD-L1) experience some form of irAEs. Different mechanisms have been postulated to explain these adverse events. Host factors such as genotype, gut microbiome and pre-existing autoimmune disorders may affect the risk of adverse events. Fatal ICI-related irAEs are due to myocarditis, colitis or pneumonitis. irAEs usually occur within the first months after ICI initiation but can develop as early as after the first dose to years after ICI initiation. Most irAEs resolve pharmacologically, but some appear to be persistent. Glucocorticoids represent the mainstay of management of irAEs, but other immunosuppressive drugs can be used to mitigate refractory irAEs. In the absence of specific trials, several guidelines, based on data from retrospective studies and expert consensus, have been published to guide the management of ICI-related irAEs.
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Affiliation(s)
- Remo Poto
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Teresa Troiani
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gjada Criscuolo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | | | - Fortunato Ciardiello
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
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30
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Lim J, Tan W, Nor N. Hints from the skin beneath: Vitiligo in Vogt–Koyanagi–Harada disease. DERMATOL SIN 2022. [DOI: 10.4103/ds.ds_23_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Immune Checkpoint Inhibitor Treatment and Ophthalmologist Consultations in Patients with Malignant Melanoma or Lung Cancer-A Nationwide Cohort Study. Cancers (Basel) 2021; 14:cancers14010049. [PMID: 35008211 PMCID: PMC8750081 DOI: 10.3390/cancers14010049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To estimate the frequency of first-time ocular events in patients treated with immune checkpoint inhibitors (ICI). METHODS Patients with cancer in 2011-2018 in Denmark were included and followed. The outcomes were first-time ophthalmologist consultation and ocular inflammation. One-year absolute risks of outcomes and hazard ratios were estimated. RESULTS 112,289 patients with cancer were included, and 2195 were treated with ICI. One year after the first ICI treatment, 6% of the patients with cancer, 5% and 8% of the lung cancer (LC) and malignant cutaneous melanoma (MM) patients, respectively, had a first-time ophthalmologist consultation. The risk of ocular inflammation was 1% (95% confidence interval (CI) 0.4-1.2). Among patients with MM, ICI was associated with ocular inflammation in women (HR 12.6 (95% CI 5.83-27.31) and men (4.87 (95% CI 1.79-13.29)). Comparing patients with and without ICI treatment, the risk of first-time ophthalmologist consultation was increased in patients with LC (HR 1.74 (95% CI 1.29-2.34) and MM (HR 3.21 (95% CI 2.31-4.44). CONCLUSIONS The one-year risks of first-time ophthalmologist consultation and ocular inflammation were 6% and 1%, respectively, in patients treated with ICI. In patients with LC and MM, the risk was increased in patients with ICI compared with patients without ICI.
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Young L, Finnigan S, Streicher H, Chen HX, Murray J, Sen HN, Sharon E. Ocular adverse events in PD-1 and PD-L1 inhibitors. J Immunother Cancer 2021; 9:jitc-2020-002119. [PMID: 34226280 PMCID: PMC8258670 DOI: 10.1136/jitc-2020-002119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2021] [Indexed: 12/15/2022] Open
Abstract
Background Programmed death-1 (PD-1) and programmed death-ligand 1 (PD-L1) inhibitors can cause unique immune-related adverse effects due to non-specific immunological activation. However, less is known about adverse effects of these drugs in the eye. Methods Two adverse event databases were retrospectively reviewed. The two databases consisted of a routine adverse event database and a serious adverse event database of expeditiously submitted reports. Patients with any malignancy who had ocular adverse events while on PD-1/PD-L1 inhibitor treatment were included. Patients received nivolumab, pembrolizumab, atezolizumab or durvalumab alone or in combination with other anticancer agents per each trial’s protocol. Databases were queried up to May 19, 2020. Results In the routine adverse event database, 272 adverse events from 213 patients were reported and in the serious adverse event reporting database, 59 ocular adverse events from 47 patients were reported. A lower estimate of the prevalance from the routine adverse event database showed 259/7727 patients on study treatment arms reporting ocular adverse events (3.3% prevalence). Excluding trials that do not report lower grade adverse events to the routine adverse event database results in a higher end estimate of 242/3255 patients on study treatment arms reporting ocular adverse events (7.4% prevalence). Ocular events occurred early after drug initiation (routine database: median 6 weeks, IQR 0–16, serious adverse events database: median 11 weeks, IQR 6–21). The median Common Terminology Criteria for Adverse Events grade was grade 1 (mild) (IQR 1–2) and grade 2 (moderate) (IQR 2–3) for the routine database and the serious adverse events database, respectively. In-depth analysis of the serious adverse event reports revealed varying degrees of clinical workup, with 30/47 patients (64%) receiving ophthalmological evaluation and 16/47 (34%) of patients having to delay or discontinue treatment. However, 16/47 (34%) patients experienced resolution and 14/47 (30%) patients experienced at least some improvement. Conclusions This is one of the largest analyses of ocular adverse events in patients treated with PD-1/PD-L1 inhibitors in the USA. We found ocular adverse events are rare complications of PD-1/PD-L1 inhibitor therapy, can be severe enough to cause treatment discontinuation/delay, and may not always be appropriately evaluated by eye specialists. Standardized plans for ophthalmology evaluation and management of ocular toxicities are needed in studies of patients treated with PD-1/PD-L1 inhibitors.
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Affiliation(s)
- LeAnne Young
- National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Shanda Finnigan
- Cancer Therapy Evaluation Program, National Cancer Institute, Rockville, Maryland, USA
| | - Howard Streicher
- Cancer Therapy Evaluation Program, National Cancer Institute, Rockville, Maryland, USA
| | - Helen X Chen
- Cancer Therapy Evaluation Program, National Cancer Institute, Rockville, Maryland, USA
| | - James Murray
- Technical Resources International, Bethesda, Maryland, USA
| | - H Nida Sen
- National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Elad Sharon
- Cancer Therapy Evaluation Program, National Cancer Institute, Rockville, Maryland, USA
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Noseda R, Bonaldo G, Motola D, Stathis A, Ceschi A. Adverse Event Reporting with Immune Checkpoint Inhibitors in Older Patients: Age Subgroup Disproportionality Analysis in VigiBase. Cancers (Basel) 2021; 13:cancers13051131. [PMID: 33800813 PMCID: PMC7961480 DOI: 10.3390/cancers13051131] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Due to the changes that occur with aging in the immune system, older patients represent a subpopulation of concern for immune checkpoint inhibitor toxicity. This pharmacovigilance study aimed to assess whether older patient age (65 years and older) was a risk factor for increased reporting of adverse drug reactions with immune checkpoint inhibitors as compared to other antineoplastic drugs in VigiBase, the World Health Organization global database of spontaneous reporting. Disproportionality analysis by age subgroups (<18 years, 18–64 years, 65–74 years, 75–84 years and ≥85 years) did not highlight older patient age as risk factor for increased reporting of any specific toxicity with immune checkpoint inhibitors as compared to other antineoplastic drugs. A signal of disproportionate reporting emerged for eye disorders with immune checkpoint inhibitors in patients aged 18–64 years, which deserves further investigation aimed at elucidating risk factors and defining management strategies. Abstract Older patients represent a subpopulation of concern for immune checkpoint inhibitor (ICI) toxicity because of changes in the aging immune system and the potentially relevant clinical implications for their quality of life. Current evidence on ICI safety in older patients is conflicting. This study aimed to assess whether older patient age was a risk factor for increased reporting with ICIs as compared to other antineoplastic drugs in VigiBase, the World Health Organization database of suspected adverse drug reactions. Disproportionality analyses computing the reporting odds ratios (RORs) were performed by age subgroups (<18 years, 18–64 years, 65–74 years, 75–84 years and ≥85 years). There were not signals of disproportionate reporting with ICIs specifically detected in older patient age subgroups (≥65 years), which were not present in the disproportionality analysis over the entire dataset. A signal of disproportionate reporting with ICIs emerged for eye disorders only in the age subgroup 18–64 years (ROR 1.13, 95% confidence interval 1.05–1.23). These findings showed that adverse event reporting with ICIs in older patients was comparable to that in the overall patient cohort and prompt for the further investigation of eye disorders with ICIs to elucidating risk factors and defining management strategies.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland;
- Correspondence: ; Tel.: +41-91-811-6300
| | - Giulia Bonaldo
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (G.B.); (D.M.)
| | - Domenico Motola
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (G.B.); (D.M.)
| | - Anastasios Stathis
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland;
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland;
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, 8091 Zurich, Switzerland
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Park RB, Jain S, Han H, Park J. Ocular surface disease associated with immune checkpoint inhibitor therapy. Ocul Surf 2021; 20:115-129. [PMID: 33610743 DOI: 10.1016/j.jtos.2021.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/07/2021] [Accepted: 02/14/2021] [Indexed: 12/12/2022]
Abstract
Immune-related adverse events (irAEs) is a term used to describe the various toxicities associated with immune checkpoint inhibitor (ICI) use. As this class of cancer immunotherapy grows, the diversity of documented irAEs also continues to expand. Ocular toxicities secondary to ICI use are relatively rare, with dry eye and uveitis as the most frequently reported ocular side effects. This article specifically investigates the relationship between ocular surface disease and ICI therapy through a review of the existing literature. Dry eye disease (DED), conjunctivitis, and keratitis were the most commonly reported irAEs affecting the ocular surface across the 29 studies reviewed. Keratoplasty graft rejection was also described in two case reports. Our review of eight clinical trials found the incidence of DED, the most common ocular surface irAE, to range from 1 to 4%. Nearly all cases of ocular surface irAEs were graded as mild or moderate in severity and were often self-limited or controlled with conservative treatment. Duration of checkpoint inhibitor use prior to onset of ocular surface side effects varied widely, ranging from days to months. Ocular surface toxicities associated with checkpoint immunotherapy appear to be under-reported and under-investigated. Further work remains to be done to investigate the full breadth of ocular surface pathologies and the molecular mechanisms by which these toxicities occur.
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Affiliation(s)
- Royce B Park
- State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA
| | - Sandeep Jain
- Department of Ophthalmology & Visual Sciences, University of Illinois at Chicago, 1855 W. Taylor St. M/C 648, Chicago, IL, 60612, USA
| | - Hui Han
- State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA
| | - Jennifer Park
- Department of Ophthalmology, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA.
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Mehraban Far P, Rullo J, Farmer J, Urton T. Recurrent Uveitis Related to Ibrutinib for Treatment of Chronic Lymphocytic Leukemia. Ocul Immunol Inflamm 2021; 30:1005-1008. [PMID: 33539715 DOI: 10.1080/09273948.2020.1841802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose: We describe a case vision-threatening sclerouveitis as a probable adverse drug reaction to ibrutinib. Methods: Case report. Results: Ibrutinib is an inhibitor of Bruton's kinase which has shown success in the treatment of hematological malignancies such as chronic lymphocytic leukemia. Despite being generally well tolerated, recent studies have implicated ibrutinib in several adverse events affecting organs such as the heart, intestines, and the eyes. We present the case of a patient who developed severe sclerouveitis after approximately one year of ibrutinib therapy, and suggest this is a probable adverse drug reaction associated with ibrutinib in accordance with the Naranjo algorithm, highlighting the importance of prompt management of ocular symptoms in these patients.
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Affiliation(s)
- Parsa Mehraban Far
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada
| | - Jacob Rullo
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada
| | - James Farmer
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada
| | - Todd Urton
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada
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Reekie IR, Sharma S, Foers A, Sherlock J, Coles MC, Dick AD, Denniston AK, Buckley CD. The Cellular Composition of the Uveal Immune Environment. Front Med (Lausanne) 2021; 8:721953. [PMID: 34778287 PMCID: PMC8586083 DOI: 10.3389/fmed.2021.721953] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/05/2021] [Indexed: 12/26/2022] Open
Abstract
The uveal tract consists of the iris, the ciliary body and the choroid; these three distinct tissues form a continuous layer within the eye. Uveitis refers to inflammation of any region of the uveal tract. Despite being grouped together anatomically, the iris, ciliary body and choroid are distinct functionally, and inflammatory diseases may affect only one part and not the others. Cellular structure of tissues direct their function, and understanding the cellular basis of the immune environment of a tissue in health, the "steady state" on which the perturbations of disease are superimposed, is vital to understanding the pathogenesis of those diseases. A contemporary understanding of the immune system accepts that haematopoietic and yolk sac derived leukocytes, though vital, are not the only players of importance. An array of stromal cells, connective tissue cells such as fibroblasts and endothelial cells, may also have a role in the inflammatory reaction seen in several immune-mediated diseases. In this review we summarise what is known about the cellular composition of the uveal tract and the roles these disparate cell types have to play in immune homeostasis. We also discuss some unanswered questions surrounding the constituents of the resident leukocyte population of the different uveal tissues, and we look ahead to the new understanding that modern investigative techniques such as single cell transcriptomics, multi-omic data integration and highly-multiplexed imaging techniques may bring to the study of the uvea and uveitis, as they already have to other immune mediated inflammatory diseases.
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Affiliation(s)
- Ian R. Reekie
- The Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
| | - Srilakshmi Sharma
- The Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford Eye Hospital, Oxford, United Kingdom
| | - Andrew Foers
- The Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
| | - Jonathan Sherlock
- The Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
| | - Mark C. Coles
- The Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
| | - Andrew D. Dick
- School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Biomedical Research Centre, Institute of Ophthalmology, Moorfields Eye Hospital, University College London, London, United Kingdom
| | - Alastair K. Denniston
- Institute for Inflammation and Ageing, College of Medical and Dental Sciences, Queen Elizabeth Hospital, University of Birmingham, Birmingham, United Kingdom
| | - Christopher D. Buckley
- The Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
- Institute for Inflammation and Ageing, College of Medical and Dental Sciences, Queen Elizabeth Hospital, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Christopher D. Buckley
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Abstract
Purpose: Immune checkpoint inhibitors are a relatively new class of medications that activate normal tumor surveillance mechanisms. These agents have tremendous utility in treating a variety of cancers and are thus being used with increasing frequency. However, these medications carry significant ophthalmic toxicities. This review aims to discuss the most common ocular side effects of immune checkpoint inhibitors.Methods: A literature search was performed to identify reports of ophthalmic side effects of immune checkpoint inhibitors. The articles were reviewed, and data was extracted.Results: Immune checkpoint inhibitors may result in a wide variety of ophthalmic complications, including ocular surface disease, uveitis, orbital inflammation, myositis and myopathy, optic nerve disease, and chorioretinal lesions. While many of these toxicities respond to topical and systemic corticosteroids, more severe presentations necessitate temporary or permanent discontinuation of therapy.Conclusions: This class of medication may yield a spectrum of ocular side effects, and ophthalmologists must be cognizant of these problems and their implications. Patient education facilitates appropriate vigilance and awareness of these issues. Coordination with the oncologic team will help to determine optimal treatment strategies.
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Affiliation(s)
- Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Albany, New York, USA
| | - Madhavi L Kambam
- Division of Oncology, Department of Medicine, Albany Medical College, Albany, New York, USA
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High Expression of Programmed Death Ligand 1 and Programmed Death Ligand 2 in Ophthalmic Sebaceous Carcinoma: The Case for a Clinical Trial of Checkpoint Inhibitors. Am J Ophthalmol 2020; 220:128-139. [PMID: 32730911 DOI: 10.1016/j.ajo.2020.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the expression of programmed death ligand 1 (PD-L1) and programmed death ligand 2 (PD-L2) in ocular adnexal sebaceous carcinoma (OASC), and to appraise these findings within the context of recent comparable studies. DESIGNS Retrospective case series. METHODS Twenty cases of primary OASC were immunostained for PD-L1, PD-L2 and CD8. PD-L1 and PD-L2 expression were graded with both the combined positive score (CPS) and the tumor proportion score (TPS). Both raw CPS and TPS were reported, as well as positivity with TPS and CPS ≥1. CD8 expression was graded on a 0-3 scale. Charts were reviewed for clinical correlations. The results of the current study were compared with results of similar recent investigations. RESULTS For the 20 cases, mean expression of PD-L1 with CPS was 29.7 (range 0-101.5) and with TPS was 12.2 (range 0-95.8); mean expression of PD-L2 with CPS was 7.9 (range 0-37.3) and with TPS was 1.9 (range 0-12.9). PD-L1 CPS ≥1 was detected in 95% of OASC, while PD-L1 TPS ≥1 was found in 75%. PD-L2 CPS ≥1 was present in 60%, while only 20% had PD-L2 TPS ≥1. Immune cells appeared to contribute to a substantial proportion of PD-L1 and PD-L2 positivity, and a conspicuous CD8-positive T-lymphocytic infiltrate was present in most tumors. Significant correlations were identified between tissue expression of PD-L1, PD-L2, and CD8. Tissues with greater levels of PD-L1 tended to express higher levels of PD-L2 and CD8. The degree of PD-L1 and PD-L2 expression was also associated with the area in millimeters squared of the immunostained tumor, suggesting that tumor sampling may influence interpretation of PD-L1 and PD-L2 expression in ocular adnexal tumors. CONCLUSIONS The current and preceding studies confirm that PD-L1 and PD-L2 are expressed in a high percentage of OASCs. These results support the premise that checkpoint inhibitor drugs hold considerable therapeutic promise for patients with OASC and stimulate the institution of clinical trials.
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Peng L, Mao QQ, Jiang B, Zhang J, Zhao YL, Teng XD, Yang JS, Xia Y, Chen SQ, Stebbing J, Jiang H. Bilateral Posterior Uveitis and Retinal Detachment During Immunotherapy: A Case Report and Literature Review. Front Oncol 2020; 10:549168. [PMID: 33240807 PMCID: PMC7680916 DOI: 10.3389/fonc.2020.549168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/29/2020] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) cause fewer toxicities than conventional chemotherapy. Although most of the immune-related adverse events (irAEs) are mild, reversible, and manageable, potentially severe and rare irAEs remain relevant. We present a 24-year-old man with advanced hereditary renal cancer who developed bilateral posterior uveitis and retinal detachment after systematic treatment of ICI and an anti-angiogenic drug. Axitinib and pembrolizumab were administered with a partial response and following the severe ocular irAE and systemic corticosteroid treatment was initiated. Our case indicates that ocular irAEs may occur rapidly. To the best of our knowledge, this is the first case of posterior uveitis and retinal detachment in hereditary renal cancer patients treated with ICI and anti-angiogenic drugs.
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Affiliation(s)
- Ling Peng
- Department of Radiotherapy, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Respiratory Disease, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Qi-Qi Mao
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bo Jiang
- Department of Ophthalmology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jin Zhang
- Department of Urology, Renji Hospital, Shanghai, China
| | - Yi-Lei Zhao
- Department of Radiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao-Dong Teng
- Department of Pathology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jin-Song Yang
- Department of Radiotherapy, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yang Xia
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Shi-Qing Chen
- The Medical Department, 3D Medicines Inc., Shanghai, China
| | - Justin Stebbing
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Hai Jiang
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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40
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Yu CW, Yau M, Mezey N, Joarder I, Micieli JA. Neuro-ophthalmic Complications of Immune Checkpoint Inhibitors: A Systematic Review. Eye Brain 2020; 12:139-167. [PMID: 33173368 PMCID: PMC7648547 DOI: 10.2147/eb.s277760] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) are novel cancer therapies that may be associated with immune-related adverse events (IRAEs) and come to the attention of neuro-ophthalmologists. This systematic review aims to synthesize the reported ICI-associated IRAEs relevant to neuro-ophthalmologists to help in the diagnosis and management of these conditions. METHODS A systematic review of the literature indexed by MEDLINE, Embase, CENTRAL, and Web of Science databases was searched from inception to May 2020. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Primary studies on ICIs and neuro-ophthalmic complications were included. Outcomes included number of cases and incidence of neuro-ophthalmic IRAEs. RESULTS Neuro-ophthalmic complications of ICIs occurred in 0.46% of patients undergoing ICI and may affect the afferent and efferent visual systems. Afferent complications include optic neuritis (12.8%), neuroretinitis (0.9%), and giant cell arteritis (3.7%). Efferent complications include myasthenia gravis (MG) (45.0%), thyroid-like eye disease (11.9%), orbital myositis (13.8%), general myositis with ptosis (7.3%), internuclear ophthalmoplegia (0.9%), opsoclonus-myoclonus-ataxia syndrome (0.9%), and oculomotor nerve palsy (0.9%). Pembrolizumab was the most common causative agent for neuro-ophthalmic complications (32.1%). Mortality was highest for MG (19.8%). Most patients (79.8%) experienced improvement or complete resolution of neuro-ophthalmic symptoms due to cessation of ICI and immunosuppression with systemic corticosteroids. CONCLUSION While incidence of neuro-ophthalmic IRAEs is low, clinicians involved in the care of cancer patients must be aware of their presentation to facilitate prompt recognition and management. Collaboration between oncology and neuro-ophthalmology teams is required to effectively manage patients and reduce morbidity and mortality.
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Affiliation(s)
- Caberry W Yu
- Faculty of Medicine, Queen’s University, Kingston, Canada
| | - Matthew Yau
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Natalie Mezey
- Faculty of Medicine, Queen’s University, Kingston, Canada
| | - Ishraq Joarder
- Faculty of Science, University of Toronto, Scarborough, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences and Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
- Kensington Vision and Research Centre, Toronto, Canada
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41
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Makri OE, Dimitrakopoulos FI, Tsapardoni F, Tsekouras I, Argyriou AA, Kalofonos H, Georgakopoulos CD. Isolated optic neuritis after pembrolizumab administration for non-small-cell lung carcinoma. Int J Neurosci 2020; 132:643-648. [PMID: 32998608 DOI: 10.1080/00207454.2020.1831489] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To report a case of isolated optic neuritis associated with pembrolizumab immunotherapy for metastatic non-small cell lung carcinoma. CASE PRESENTATION A 76-year-old man, with a history of metastatic non-small cell lung carcinoma, presented with vision loss in his left eye for the past week. He had been treated with pembrolizumab for the underlying disease for 2 months. On presentation, best corrected visual acuity was 20/30 in the right eye and 20/200 in the left eye. Fundoscopy revealed optic nerve edema in the left eye. Visual fields examination in right eye revealed an enlarged blind spot and an extended defect in the inferior nasal quadrant. In the left eye a partial superior arcuate defect and an extended defect in the inferior hemisphere was observed. The mean deviation was -12.15 dB in the right eye and -13.70 dB in left eye. Pembrolizumab was withheld and corticosteroids were administered for a total of nine weeks, first intravenously and then slowly tapered orally, resulting in resolution of optic neuritis, restoration of visual acuity and in relative improvement in the visual field defects after 3 months. Calculated Naranjo Nomogram score was 7, indicating a 'highly probable' correlation. CONCLUSIONS Optic neuritis is a relatively rare immune-related adverse event after exposure to checkpoint inhibitors cancer immunotherapy. Prompt discontinuation of the offending agent and early initiation of corticosteroid therapy is the mainstay of the treatment.
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Affiliation(s)
- Olga E Makri
- Department of Ophthalmology, Medical School, University of Patras, Patras, Greece
| | | | - Foteini Tsapardoni
- Department of Ophthalmology, Medical School, University of Patras, Patras, Greece
| | - Iasonas Tsekouras
- Department of Ophthalmology, Medical School, University of Patras, Patras, Greece
| | | | - Haralabos Kalofonos
- Division of Oncology, Department of Medicine, Medical School, University of Patras, Patras, Greece
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42
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Cunningham ET, Moorthy RS, Zierhut M. Immune Checkpoint Inhibitor-Induced Uveitis. Ocul Immunol Inflamm 2020; 28:847-849. [DOI: 10.1080/09273948.2020.1801286] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Emmett T. Cunningham
- The Department of Ophthalmology, California Pacific Medical Center, San Francisco, California, USA
- The Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA
- UCSF School of Medicine, The Francis I. Proctor Foundation, San Francisco, California, USA
| | - Ramana S. Moorthy
- Associated Vitreoretinal and Uveitis Consultants, Indianapolis, Indiana, USA
- Department of Ophthalmology, Indiana University Medical Center, Indianapolis, Indiana, USA
- St. Vincent Hospital and Health Services, Indianapolis, Indiana, USA
| | - Manfred Zierhut
- Centre for Ophthalmology, University Tuebingen, Tuebingen, Germany
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43
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Narala R, Reddy SA, Mruthyunjaya P. "Giant cell arteritis manifesting as retinal arterial occlusion and paracentral acute middle maculopathy in a patient on pembrolizumab for metastatic uveal melanoma". Am J Ophthalmol Case Rep 2020; 20:100891. [PMID: 32913923 PMCID: PMC7472807 DOI: 10.1016/j.ajoc.2020.100891] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/09/2020] [Accepted: 08/18/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To report the association of pembrolizumab, an immune checkpoint inhibitor (ICI), with giant cell arteritis (GCA) presenting as paracentral acute middle maculopathy (PAMM) secondary to retinal arterial occlusion. Observations 86-year old male with history of treated choroidal melanoma now with metastatic uveal melanoma to the liver on pembrolizumab, an ICI, who presented with acute vision loss in the uninvolved left eye. Spectral domain optical coherence tomography showed band-like increased hyperreflectivity in the middle retinal layers at the level of the inner nuclear layer consistent with PAMM. Intravenous fluorescein angiogram demonstrated significant delay in filling of the superotemporal and inferotemporal arteries with nonperfusion of the temporal retina consistent with multiple branch retinal arterial occlusions. Work-up for GCA was performed and temporal artery biopsy showed healed arteritis. Conclusions and Importance Pembrolizumab can cause ocular and life-threatening systemic adverse effects and as use of ICIs has increased, it is important to be aware of these associations. There should be a low threshold for GCA work up in patients on ICI therapy who present with acute vision loss and evidence of retinal occlusive disease with or without classic GCA systemic symptoms.
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Affiliation(s)
- Ramsudha Narala
- Stanford University Medical Center, Department of Ophthalmology, Palo Alto, CA, USA.,Stanford University Medical Center, Department of Medicine, Palo Alto, CA, USA
| | - Sunil A Reddy
- Stanford University Medical Center, Department of Ophthalmology, Palo Alto, CA, USA.,Stanford University Medical Center, Department of Medicine, Palo Alto, CA, USA
| | - Prithvi Mruthyunjaya
- Stanford University Medical Center, Department of Ophthalmology, Palo Alto, CA, USA.,Stanford University Medical Center, Department of Medicine, Palo Alto, CA, USA
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44
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Bomze D, Meirson T, Hasan Ali O, Goldman A, Flatz L, Habot-Wilner Z. Ocular Adverse Events Induced by Immune Checkpoint Inhibitors: A Comprehensive Pharmacovigilance Analysis. Ocul Immunol Inflamm 2020; 30:191-197. [DOI: 10.1080/09273948.2020.1773867] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- David Bomze
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Institute for Immunobiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Tomer Meirson
- Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Omar Hasan Ali
- Institute for Immunobiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Adam Goldman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Lukas Flatz
- Institute for Immunobiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel
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45
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Kim YJ, Lee JS, Lee J, Lee SC, Kim TI, Byeon SH, Lee CS. Factors associated with ocular adverse event after immune checkpoint inhibitor treatment. Cancer Immunol Immunother 2020; 69:2441-2452. [PMID: 32556494 DOI: 10.1007/s00262-020-02635-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022]
Abstract
Ocular adverse events (OAEs) including vision-threatening intraocular inflammation after immune checkpoint inhibitor (ICI) treatment have been increasingly reported; however, the risk factors associated with OAEs remain elusive. Here, we determined the factors associated with OAEs after ICI treatment. We analyzed 40 consecutive patients who experienced OAEs after ICI treatments. The OAEs included anterior uveitis, chorioretinitis, papillitis, foveal interdigitation zone thickening/serous retinal detachment (IZT/SRD), retinal vascular occlusion, and strabismus and ptosis. Of 40 patients, 18 (45%) were treated with atezolizumab, 13 (33%) with pembrolizumab, 7 (18%) with nivolumab, 1 (3%) with ipilimumab/nivolumab, and the other 1 (3%) with durvalumab/tremelimumab. BRAF/MEK inhibitors were concurrently used in 19 (48%) patients. Occurrence of intraocular inflammation was significantly associated with previous ocular surgery and trauma history (P = 0.015) and pembrolizumab use (P = 0.031). Neuro-ophthalmic complications and IZT/SRD were associated with brain metastasis (P = 0.005) and treatment with BRAF/MEK inhibitor (P < 0.001), respectively. In extensive literature review for clinical cases, we identified seven cases with intraocular inflammation, which were not observed with ipilimumab treatment, that occurred after a change of the drug to pembrolizumab. Collectively, these findings provide better understandings of OAEs after ICI treatment.
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Affiliation(s)
- Yong Joon Kim
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, Republic of Korea
| | - Jihei Sara Lee
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, Republic of Korea
| | - Junwon Lee
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, Republic of Korea
| | - Sung Chul Lee
- Department of Ophthalmology, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Tae-Im Kim
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, Republic of Korea
| | - Suk Ho Byeon
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, Republic of Korea
| | - Christopher Seungkyu Lee
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, Republic of Korea.
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46
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Kähler KC, Hassel JC, Heinzerling L, Loquai C, Thoms KM, Ugurel S, Zimmer L, Gutzmer R. Side effect management during immune checkpoint blockade using CTLA-4 and PD-1 antibodies for metastatic melanoma - an update. J Dtsch Dermatol Ges 2020; 18:582-609. [PMID: 32489011 DOI: 10.1111/ddg.14128] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
CTLA-4 and PD-1 play a key role in tumor-induced downregulation of lymphocytic immune responses. Immune checkpoint inhibitors have been shown to alter the immune response to various cancer types. Anti-CTLA-4 and anti-PD-1 antibodies affect the interaction between tumor, antigen-presenting cells and T lymphocytes. Clinical studies of the anti-CTLA-4 antibody ipilimumab and the anti-PD-1 antibodies nivolumab and pembrolizumab have provided evidence of their positive effects on overall survival in melanoma patients. Combined treatment using ipilimumab and nivolumab has been shown to achieve five-year survival rates of 52 %. Such enhancement of the immune response is inevitably associated with adverse events. Knowledge of the spectrum of side effects is essential, both in terms of prevention and management. Adverse events include colitis, dermatitis, hypophysitis, thyroiditis, hepatitis and other, less common autoimmune phenomena. In recent years, considerable progress has been made in the detection and treatment of the aforementioned immune-related adverse events. However, early diagnosis of rare neurological or cardiac side effects, which may be associated with increased mortality, frequently pose a challenge. The present update highlights our current understanding as well as new insights into the spectrum of side effects associated with checkpoint inhibitors and their management.
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Affiliation(s)
- Katharina C Kähler
- Department of Dermatology, Venereology and Allergology, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases, University Medical Center, Heidelberg, Germany
| | - Lucie Heinzerling
- Department of Dermatology, University Medical Center, Erlangen, Germany
| | - Carmen Loquai
- Department of Dermatology, University Medical Center, Mainz, Germany
| | - Kai-Martin Thoms
- Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Medical Center, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venereology and Allergology, University Medical Center, Essen, Germany
| | - Ralf Gutzmer
- Department of Dermatology, Venereology and Allergology, Skin Cancer Center, Hanover Medical School, Hanover, Germany
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47
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Kähler KC, Hassel JC, Heinzerling L, Loquai C, Thoms K, Ugurel S, Zimmer L, Gutzmer R. Nebenwirkungsmanagement bei Immun‐Checkpoint‐Blockade durch CTLA‐4‐ und PD‐1‐Antikörper beim metastasierten Melanom – ein Update. J Dtsch Dermatol Ges 2020; 18:582-609. [DOI: 10.1111/ddg.14128_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Katharina C. Kähler
- Klinik für Dermatologie Venerologie und Allergologie Universitätsklinikum Schleswig‐Holstein Campus Kiel
| | - Jessica C. Hassel
- Hautklinik und Nationales Centrum für Tumorerkrankungen Universitätsklinikum Heidelberg
| | | | | | - Kai‐Martin Thoms
- Klinik für Dermatologie Venerologie und Allergologie Universitätsmedizin Göttingen
| | - Selma Ugurel
- Klinik für Dermatologie Venerologie und Allergologie Universitätsklinikum Essen
| | - Lisa Zimmer
- Klinik für Dermatologie Venerologie und Allergologie Universitätsklinikum Essen
| | - Ralf Gutzmer
- Klinik für Dermatologie Allergologie und Venerologie Hauttumorzentrum Hannover Medizinische Hochschule Hannover
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48
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Ahmad TR, Doan T, Gonzales JA, Acharya NR, Tsui E. Clinical Course of Preexisting Uveitis during Treatment of Lung Cancer with Durvalumab. Ocul Immunol Inflamm 2020; 28:566-570. [PMID: 31710511 DOI: 10.1080/09273948.2019.1678652] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Tessnim R Ahmad
- School of Medicine, University of California , San Francisco, California, USA
| | - Thuy Doan
- F.I. Proctor Foundation, University of California , San Francisco, California, USA.,Department of Ophthalmology, David Geffen School of Medicine, University of California , Los Angeles, California, USA
| | - John A Gonzales
- F.I. Proctor Foundation, University of California , San Francisco, California, USA.,Department of Ophthalmology, David Geffen School of Medicine, University of California , Los Angeles, California, USA
| | - Nisha R Acharya
- F.I. Proctor Foundation, University of California , San Francisco, California, USA.,Department of Ophthalmology, David Geffen School of Medicine, University of California , Los Angeles, California, USA
| | - Edmund Tsui
- F.I. Proctor Foundation, University of California , San Francisco, California, USA.,Department of Ophthalmology, David Geffen School of Medicine, University of California , Los Angeles, California, USA.,UCLA Stein Eye Institute, Los Angeles, California, USA
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49
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Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target inhibitory molecules, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), or its ligand, programmed cell death protein ligand 1 (PD-L1), and lead to immune activation in the tumor micro-environment. ICIs can induce durable treatment responses in patients with advanced cancers, but they are commonly associated with immune related adverse events (irAEs) such as rash, colitis, hepatitis, pneumonitis, and endocrine and musculoskeletal disorders. Almost all patients experience some form of irAE, but high grade irAEs occur in approximately half of those on combination therapy (eg, anti-CTLA-4 plus anti-PD-1), and up to one quarter receiving ICI monotherapy. Fatal irAEs occur in approximately 1.2% of patients on CTLA-4 blockade and 0.4% of patients receiving PD-1 or PD-L1 blockade, and case fatality rates are highest for myocarditis and myositis. IrAEs typically occur in the first three months after ICI initiation, but can occur as early as one day after the first dose to years after ICI initiation. The mainstay of treatment is with corticosteroids, but tumor necrosis factor inhibitors are commonly used for refractory irAEs. Although ICIs are generally discontinued when high grade irAEs occur, ICI discontinuation alone is rarely adequate to resolve irAEs. Consensus guidelines have been published to help guide management, but will likely be modified as our understanding of irAEs grows.
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Affiliation(s)
- Karmela K Chan
- Weill Cornell Medicine, Hospital for Special Surgery, New York, USA
| | - Anne R Bass
- Weill Cornell Medicine, Hospital for Special Surgery, New York, USA
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