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Shawer R, Solomon A. Adverse effects of anti-cancer biologics on the ocular surface. Curr Opin Allergy Clin Immunol 2024; 24:390-396. [PMID: 38963724 DOI: 10.1097/aci.0000000000001007] [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: 07/06/2024]
Abstract
PURPOSE OF REVIEW Cancer immunotherapy is one of the most emerging and rapidly growing fields.Ocular side effects associated with these therapies are common and can be present in up to 70% of patients.The cornea may be involved in different pathogenic mechanisms triggered by different immunotherapeutic agents, and corneal disease varies from mild symptoms to severe corneal ulceration and melting with visual loss.We aimed to review the incidence, mechanism, and management of ocular surface side effects in cancer patients receiving immunotherapy. RECENT FINDINGS With the recent use of immunotherapeutic agents in cancer patients, in particular immune checkpoint inhibitors (ICIs) and epidermal growth factor receptor (EGFR) inhibitors, ocular surface and corneal involvement are common side effects.These patients can be at risk of sight threatening complications that warrant prompt diagnosis and careful monitoring and management. SUMMARY Immunotherapy- related corneal complications in cancer patients are associated with a decreased quality of life. Prompt recognition and an interdisciplinary approach between ophthalmologists and oncologists are crucial to handle immune related ocular adverse events in these patients, in order to maintain ocular surface integrity and avoid a vision threatening complication.
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Affiliation(s)
- Riham Shawer
- Department of Ophthalmology, Hadassah-Hebrew University Medical Centre
- St. John Eye Hospital, Jerusalem, Israel
| | - Abraham Solomon
- Department of Ophthalmology, Hadassah-Hebrew University Medical Centre
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2
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Quiruz L, Yavari N, Kikani B, Gupta AS, Wai KM, Kossler AL, Ludwig C, Koo EB, Rahimy E, Mruthyunjaya P. Ophthalmic Immune-Related Adverse Events and Association with Survival: Results from a Real-World Database. Am J Ophthalmol 2024:S0002-9394(24)00416-1. [PMID: 39271090 DOI: 10.1016/j.ajo.2024.08.044] [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: 06/26/2024] [Revised: 08/24/2024] [Accepted: 08/30/2024] [Indexed: 09/15/2024]
Abstract
PURPOSE Assessing immune-related ocular toxicities from immune checkpoint inhibitors (ICIs) is crucial, though rare. This study, utilizing real-world data, examines the occurrence of ophthalmic immune-related adverse events (irAEs) after ICI treatment and their impact on overall survival. DESIGN A retrospective cohort study METHODS: Data were obtained from TriNetX, an aggregated electronic health records database. Patients who developed ophthalmic irAEs within 1 year after the first instance of ICI therapy were included. Participants with defined ocular toxicities 6 months before ICI treatment were excluded. Subjects were paired with controls using propensity scores derived from demographics and cancer type. A Cox proportional hazard model was used to determine hazard ratios. A Kaplan-Meier survival function was evaluated with the log-rank test based on the development of ophthalmic irAEs in a 12-month landmark analysis. RESULTS A cohort of 41,020 patients comprising 57.4% males with a mean age of 65.2±11.9 years was included. The five most prevalent ophthalmic irAEs in this cohort were dry eye syndrome (2%), conjunctivitis (0.87%), blepharitis (0.51%), anterior uveitis (0.39%), and keratitis (0.38%). Dry eye syndrome was the most common irAE among all ICI classes. Subjects taking CTLA-4 inhibitor plus PD-1 inhibitor and CTLA-4 inhibitors had higher rates of anterior uveitis (1.39% and 1.29%, respectively) than PD-1 inhibitors (0.27%) and PD-L1 inhibitors (0.14%) within 1 year after taking ICI. After a 12-month landmark analysis, there was a significant decreased chance of survival for the following categories: any ophthalmic irAE (HR, 1.37; 95% CI, 1.20-1.56; P < 0.0001), neuro-ophthalmic irAE (HR, 1.53; 95% CI, 1.09-2.14; P = 0.0124), and cornea and ocular surface irAE (HR, 1.34; 95% CI, 1.15-1.56; P < 0.0001). CONCLUSIONS Ophthalmic irAEs involving the anterior segment are more frequent than the posterior segment, regardless of ICI class. Ophthalmic irAEs may also portend decreased survival. This insight could help guide clinicians aggressively manage irAEs and allow patients to continue ICI therapy despite having ocular issues.
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Affiliation(s)
- Lee Quiruz
- Upstate Medical University College of Medicine, Syracuse, New York, USA
| | - Negin Yavari
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Bijal Kikani
- Upstate Medical University College of Medicine, Syracuse, New York, USA
| | - Ankur Sudhir Gupta
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Karen Michelle Wai
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Andrea Lora Kossler
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Chase Ludwig
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Eubee Baughn Koo
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ehsan Rahimy
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Prithvi Mruthyunjaya
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA.
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Sunyur AM, Alkhayat D, Mohammad HA, Alahmadi HA, Alharbi LA, Khawaji ZY, Badawi AS. Clinical Patterns and Factors Contributing to Ophthalmic and Otologic Events Associated With Immune Checkpoint Inhibitors: A Narrative Review. Cureus 2024; 16:e66611. [PMID: 39258067 PMCID: PMC11386091 DOI: 10.7759/cureus.66611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2024] [Indexed: 09/12/2024] Open
Abstract
Immune checkpoint inhibitors, which are a type of cancer immunotherapy, have been associated with the development of adverse events related to an overactive immune system caused by the effect of this type of therapy. It affects a wide range of organs, including the ear and eye. Ophthalmic toxicity related to immune checkpoint inhibitors usually occurs bilaterally. Corneal toxicity (mainly dry eye disease) and uveitis are the most commonly reported patterns of toxicity. Other patterns of involvement include optic neuritis, serous retinal detachment, keratitis, ophthalmoplegia, and ocular myasthenia, but are not limited to them. Potential factors contributing to the development of toxicity are age, previous history of ocular immune disease, type, doses, and duration of treatment, and race. Ototoxicity is also reported in the literature, usually manifesting as bilateral, symmetrical/asymmetrical hearing loss. Ear toxicity presenting as ear fullness, tinnitus, and vertigo has also been mentioned in the literature. Hearing loss is often associated with word/speech recognition. An audiogram usually shows a pattern of sensorineural hearing loss. Otitis media has also been reported to be a potential cause of ear toxicity. Immune checkpoint inhibitor toxicity was present more commonly when used along with other anti-neoplastic agents. Ear toxicity, which presumably results from damage to the melanocytes in the ear, often presents with other melanocytotic manifestations, like uveitis and vitiligo. According to the literature, some agents (ipilimumab, nivolumab, atezolizumab, and pembrolizumab) were more commonly associated with toxic effects on the eye and ear and more when combined with each other.
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Affiliation(s)
- Amal M Sunyur
- Medicine and Surgery, Taibah University, Medina, SAU
| | - Duaa Alkhayat
- Department of Clinical Oncology, Taibah University, Medina, SAU
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4
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Brown AC, Quiroz J, Parikh DA, Li Y, Ritzer L, Rosen R, Deobhakta A. Cytokines in PD-1 immune checkpoint inhibitor adverse events and implications for the treatment of uveitis. BMC Ophthalmol 2024; 24:312. [PMID: 39075390 PMCID: PMC11285394 DOI: 10.1186/s12886-024-03575-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 07/15/2024] [Indexed: 07/31/2024] Open
Abstract
Immune checkpoint inhibitors (ICI) such as Programmed cell Death 1 (PD-1) inhibitors have improved cancer treatment by enhancing the immune system's ability to target malignant cells. Their use is associated with immune-related adverse events (irAEs), including uveitis. The profile of pro-inflammatory cytokines underlying Anti-PD-1-induced uveitis shares significant overlap with that of non-infectious uveitis. Current corticosteroid treatments for uveitis while effective are fraught with vision threatening side effects. The cytokine profile in ICI-related uveitis has a large overlap with that of noninfectious uveitis, this overlap strongly supports the potential for therapy that activates the PD-1 axis in the eye to treat uveitis. Indeed, ICI related uveitis often resolves with cessation of the ICI, restoring the endogenous PD-1 axis. The potential benefit of targeting many pro-inflammatory cytokines via local PD-1 axis activation is mitigating ocular inflammation while minimizing adverse effects.
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Affiliation(s)
- Aaron C Brown
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th Street, New York, NY, 10003, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - José Quiroz
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th Street, New York, NY, 10003, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Devayu A Parikh
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th Street, New York, NY, 10003, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yafeng Li
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Lukas Ritzer
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard Rosen
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th Street, New York, NY, 10003, USA
- Einhorn Clinical Research Center, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
| | - Avnish Deobhakta
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th Street, New York, NY, 10003, USA.
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, 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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7
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Kilani A, Vounotrypidis E, König SF, Wolf A. Retinal Toxicity after Initial Administration of Nivolumab and Ipilimumab. Case Rep Ophthalmol Med 2023; 2023:9931794. [PMID: 38155755 PMCID: PMC10754639 DOI: 10.1155/2023/9931794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023] Open
Abstract
Background To present a rare case of a bilateral immune checkpoint inhibitor- (ICI-) induced photoreceptor injury with a bacillary layer detachment (BALAD) and a dissection of the photoreceptor inner and outer segment, accompanied by ICI-induced Vogt-Koyanagi-Harada- (VKH-) like uveitis after initial administration of nivolumab and ipilimumab. Case Presentation. A 52-year-old female with metastatic malignant cutaneous melanoma experiencing bilateral progressive visual acuity reduction, after treatment initiation with 1 mg/kg nivolumab and 3 mg/kg ipilimumab two weeks prior symptom onset. An extensive laboratory workup, including uveitis workup, onconeuronal and retinal antibodies, ruled out a paraneoplastic autoimmune disorder and a granulomatous disease. Furthermore, a B-scan was performed to exclude a posterior scleritis. Ensuing temporary treatment discontinuation of nivolumab and complete discontinuation of ipilimumab, treatment with high-dose systemic steroids was initiated, which resulted in alleviation of her symptoms and stability of ocular findings. Conclusions ICIs can induce significant ocular side effects. As ocular inflammation can be well controlled using systemic steroids, treatment with ICIs can be continued whenever possible, in particular, if there is a good treatment response of the systemic malignancy.
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Affiliation(s)
- Adnan Kilani
- Department of Ophthalmology, University Hospital Ulm, Prittwitzstraße 43, 89075 Ulm, Germany
| | | | - Susanna F. König
- Department of Ophthalmology, University Hospital Ulm, Prittwitzstraße 43, 89075 Ulm, Germany
| | - Armin Wolf
- Department of Ophthalmology, University Hospital Ulm, Prittwitzstraße 43, 89075 Ulm, Germany
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Sada I, Harada Y, Hiyama T, Mizukami M, Kan T, Kawai M, Kiuchi Y. Uveitis associated with immune checkpoint inhibitors or BRAF/MEK inhibitors in patients with malignant melanoma. Melanoma Res 2023; 33:539-546. [PMID: 37788106 DOI: 10.1097/cmr.0000000000000933] [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: 10/05/2023]
Abstract
The objective of this study was to evaluate the frequency and characteristics of uveitis associated with immune checkpoint inhibitors (ICIs) or BRAF/MEK inhibitors (B/MIs) in patients with malignant melanoma. Patients diagnosed with malignant melanoma who underwent radical or local resection for malignant melanoma, regardless of clinical stage or postoperative adjuvant therapy, at Hiroshima University Hospital from January 2015 to June 2021 were enrolled in a retrospective cohort. The medical records of patients were collected to estimate the prevalence of ocular adverse events. The clinical characteristics of patients who developed uveitis were reviewed. Among 152 patients, 54 and 12 were treated with ICIs and B/MIs, respectively. Four patients developed uveitis; 1 in the ICI group and 3 in the B/MI group, while there were no uveitis cases among patients who did not receive ICIs or B/MIs. Three patients had Vogt-Koyanagi-Harada disease-like findings. Uveitis was improved by steroid therapy with or without oncological treatment interruption. Oncological treatment could be resumed. Patients with melanoma treated with ICIs or B/MIs had a higher risk of uveitis compared with those who did not receive them. Oncological treatment could be resumed in all patients who developed uveitis.
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Affiliation(s)
- Ikuyo Sada
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University
| | - Yosuke Harada
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University
| | - Tomona Hiyama
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University
| | - Mina Mizukami
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University
| | - Takanobu Kan
- Department of Dermatology, Graduate School of Biomedical Sciences, Hiroshima University, Minami-ku, Hiroshima, Japan
| | - Mikio Kawai
- Department of Dermatology, Graduate School of Biomedical Sciences, Hiroshima University, Minami-ku, Hiroshima, Japan
| | - Yoshiaki Kiuchi
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University
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Takeuchi M, Meguro A, Nakamura J, Chikagawa R, Osada R, Shibuya E, Hasumi Y, Yamada N, Ishihara M, Mizuki N. HLA-DRB1*04:05 is involved in the development of Vogt-Koyanagi-Harada disease-like immune-related adverse events in patients receiving immune checkpoint inhibitors. Sci Rep 2023; 13:13580. [PMID: 37604934 PMCID: PMC10442432 DOI: 10.1038/s41598-023-40565-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/13/2023] [Indexed: 08/23/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) activate anti-tumor activity by inhibiting immune checkpoint molecules that suppress inflammatory T-cell activity. However, ICIs can initiate excessive immune responses, thereby causing immune-related adverse events (irAEs). ICI-associated uveitis (ICIU) is an irAE that affects the eyes. Although Vogt-Koyanagi-Harada disease (VKH)-like uveitis is a common form of ICIU, it is unclear which factors determine the ICIU form. We retrospectively reviewed the medical records of nine ICIU cases treated with ICIs for malignancies. We also performed HLA typing in seven cases to investigate the association between HLA and disease type. Fisher's exact test was used for the statistical analysis. Five of the ICIU cases were VKH-like ICIUs, and four were non-VKH-like ICIUs. No association was found between mean age, sex, primary disease, ICI, time to onset, and disease type. Four patients with VKH-like uveitis underwent HLA genotyping and were all positive for HLA-DRB1*04:05. All 3 patients with non-VKH-like uveitis were negative for HLA-DRB1*04:05. Statistical analysis showed that HLA-DRB1*04:05 was significantly associated with developing VKH-like ICIU (P = 0.029). In ICIU, HLA-DRB1*04:05 was associated with the pathogenesis of VKH-like uveitis, suggesting that ICI-associated VKH-like uveitis has a similar pathogenesis to VKH.
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Affiliation(s)
- Masaki Takeuchi
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
| | - Akira Meguro
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Jutaro Nakamura
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Rei Chikagawa
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Raiga Osada
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Etsuko Shibuya
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Yukiko Hasumi
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Norihiro Yamada
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Mami Ishihara
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Nobuhisa Mizuki
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
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Raheem F, Alsuhebany N, Hickey Zacholski E, Paulic N, Sandler A, Uk N, Moore DC. Ocular toxicities associated with antibody drug conjugates and immunotherapy in oncology: clinical presentation, pathogenesis, and management strategies. Expert Opin Drug Saf 2023; 22:921-928. [PMID: 37612255 DOI: 10.1080/14740338.2023.2251380] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION The development of molecularly targeted anticancer therapies and immunotherapy continues to revolutionize the treatment of cancer. FDA accelerated approvals of novel targeted therapies allowed for introduction of these agents into the clinic at a rapid rate. On-and off-target ocular toxicities are prevalent treatment-related adverse events of newer therapies including antibody drug conjugates (ADCs) and immunotherapy. Ocular toxicities associated with ADCs and immunotherapy have heterogeneous presentations and pathogenesis requiring unique and often complex monitoring, and management. AREAS COVERED In this article, we provide an updated review of treatment-emergent ocular toxicity associated with new and novel oncologic therapies and summarize guidelines and best practice strategies for prevention, monitoring and management. A literature search was performed through PubMed, ClinicalTrials.gov, and FDA website (1 January 2017 to 10 May 2023) to identify relevant information. EXPERT OPINION The implementation of a strategy for monitoring, prevention, and management of treatment-related ocular toxicities involves a multi-disciplinary, often cross-center approach. Communication with infusion nursing leadership, clinic staff, and eye care providers is crucial to the successful implementation of eye care plans to prevent and manage ocular toxicity.
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Affiliation(s)
- Farah Raheem
- Clinical Pharmacy Specialist, Hematology/Oncology, Assistant Professor of Pharmacy, Mayo Clinic College of Medicine and Science, Mayo Clinic Arizona, Phoenix, USA
| | - Nada Alsuhebany
- College of Pharmacy, oncology clinical pharmacist, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Erin Hickey Zacholski
- Clinical Pharmacy Specialist, Gynecologic Oncology, VCU Health, Massey Cancer Center, Virginia Commonwealth University (VCU) School of Pharmacy, Richmond, VA, USA
| | - Nikola Paulic
- Clinical Pharmacy Specialist, Oncology, Hospitals Geauga Medical Center, Willoughby, OH, USA
| | - Anna Sandler
- College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Nathan Uk
- College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Donald C Moore
- Clinical Oncology Pharmacy Manager, Atrium Health Levine Cancer Institute, Charlotte, NC, USA
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Kong X, Chen L, Su Z, Sullivan RJ, Blum SM, Qi Z, Liu Y, Huo Y, Fang Y, Zhang L, Gao J, Wang J. Toxicities associated with immune checkpoint inhibitors: a systematic study. Int J Surg 2023; 109:1753-1768. [PMID: 37132038 PMCID: PMC10389211 DOI: 10.1097/js9.0000000000000368] [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: 11/07/2022] [Accepted: 03/12/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Available evidence shows that the incidence of toxicities associated with cancer immunotherapy, such as programmed cell death 1 (PD-1) and programmed cell death 1 ligand 1 (PD-L1)-related toxicities, is estimated to be between 0.3 and 1.3%. OBJECTIVE This systematic review aimed to investigate cancer patients' susceptibility to toxicities associated with PD-1/PD-L1 inhibitors and establish a clinically relevant landscape of side effects of PD-1/PD-L1 inhibitors. DATA SOURCES Relevant publications from PubMed, Embase, Cochrane Library, Web of Science, and China National Knowledge Infrastructure (CNKI) between 2014 and 2019. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS We searched randomized controlled trials (RCTs) reporting treatment-related toxicities associated with PD-1 and PD-L1 inhibitors in the treatment of cancers. The primary endpoint was to assess the difference in the incidences of toxicities between cancer patients who did and did not receive PD-1/PD-L1 inhibitors. A total of 29 RCTs, incorporating 8576 patients, met the eligibility criteria. STUDY APPRAISAL AND SYNTHESIS METHODS We calculated the pooled relative risks and corresponding 95% CIs using a random-effects model and assessed the heterogeneity between different groups. The subgroup analyses were conducted based on cancer type, toxicity grade (severity), system and organ, treatment regimens in the intervention arm and the control arm, PD-1/PD-L1 inhibitor drug type, and cancer type. RESULTS A total of 11 categories (e.g. endocrine toxicity), and 39 toxicity types (e.g. hyperthyroidism) were identified. For toxicities at any grade, those treated with PD-1/PD-L1 inhibitors were at lower risks for gastrointestinal toxicity, hematologic toxicity, and treatment event leading to discontinuation; and were at higher risks for respiratory toxicity (all P <0.05). Those treated with PD-1/PD-L1 inhibitors were at lower risks for fatigue, asthenia, and peripheral edema and were at higher risks for pyrexia, cough, dyspnea, pneumonitis, and pruritus. LIMITATIONS The present research is a meta-analysis at the study level rather than at the patient level; insights on risk factors associated with the development of toxicities cannot be found in our study. There was a possible overlap in Common Terminology Criteria for Adverse Events (CTCAE) definitions which prevents understanding the true rates of specific toxicities. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS For most toxicity types based on system and organ, the incidence proportions for patients in the intervention arm were lower than those in the control arm, which suggested the general safety of PD-1/PD-L1 inhibitors against conventional chemotherapy and cytotoxic t-lymphocyte-associated protein 4 (CTLA-4) inhibitors. Future research should focus on taking effective targeted measures to decrease the risks of different toxicities for different patient populations. SYSTEMATIC REVIEW REGISTRATION NUMBER We registered the research protocol with PROSPERO (registration number CRD42019135113).
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Affiliation(s)
- Xiangyi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Li Chen
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Thyroid and Breast Surgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhaohui Su
- Center on Smart and Connected Health Technologies, Mays Cancer Center, School of Nursing, UT Health San Antonio, San Antonio,Texas, United States of America
| | - Ryan J. Sullivan
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Steven M. Blum
- Department of Medicine-Oncology, Dana-Farber Cancer Institute, Harvard Medical School,Harvard University, Boston, Massachusetts, United States of America
| | - Zhihong Qi
- Clinical Laboratory, Peking Union Medical College Hospital, China
| | - Yulu Liu
- Fintech Lab, Department of Computer Science, Chow Yei Ching Building, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Yujia Huo
- Suzhou Industrial Park Monash Research Institute of Science and Technology, Suzhou, China
| | - Yi Fang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Zhang
- Suzhou Industrial Park Monash Research Institute of Science and Technology, Suzhou, China
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- The School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Jidong Gao
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Jing Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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12
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Casselman P, Jacob J, Schauwvlieghe PP. Relation between ocular paraneoplastic syndromes and Immune Checkpoint Inhibitors (ICI): review of literature. J Ophthalmic Inflamm Infect 2023; 13:16. [PMID: 37022562 PMCID: PMC10079794 DOI: 10.1186/s12348-023-00338-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/11/2023] [Indexed: 04/07/2023] Open
Abstract
PURPOSE To describe different ocular paraneoplastic syndromes in patients treated with Immune Checkpoint Inhibitors (ICI), its relation with different types of ICI and different types of tumors, and its implications for treatment. METHODS A comprehensive review of the literature was performed. RESULTS Patients treated with ICI can present with different ocular paraneoplastic syndromes, such as Carcinoma Associated Retinopathy (CAR), Melanoma Associated Retinopathy (MAR) and paraneoplastic Acute Exudative Polymorphous Vitelliform Maculopathy (pAEPVM). In literature, the different types of paraneoplastic retinopathy are mostly related to different types of primary tumors, with MAR and pAEPVM seen in melanoma, and CAR in carcinoma. Visual prognosis is limited in MAR and CAR. CONCLUSION Paraneoplastic disorders result from an antitumor immune response against a shared autoantigen between the tumor and ocular tissue. ICI enhance the antitumor immune response, which can lead to increased cross-reaction against ocular structures and unmasking of a predisposed paraneoplastic syndrome. Different types of primary tumors are related to different cross-reactive antibodies. Therefore, the different types of paraneoplastic syndromes are related to different types of primary tumors and are probably unrelated to the type of ICI. ICI-related paraneoplastic syndromes often lead to an ethical dilemma. Continuation of ICI treatment can lead to irreversible visual loss in MAR and CAR. In these cases overall survival must be weighed against quality of life. In pAEPVM however, the vitelliform lesions can disappear with tumor control, which may involve continuation of ICI.
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Affiliation(s)
- Pauline Casselman
- Department of Ophthalmology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Julie Jacob
- Department of Ophthalmology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
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13
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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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14
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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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15
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Baldwin XL, Spanheimer PM, Downs-Canner S. A Review of Immune Checkpoint Blockade for the General Surgeon. J Surg Res 2023; 281:289-298. [PMID: 36228339 PMCID: PMC10029124 DOI: 10.1016/j.jss.2022.08.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/01/2022] [Accepted: 08/20/2022] [Indexed: 11/21/2022]
Abstract
The immune system is a complex and interconnected system that has evolved to protect its host from foreign pathogens. CD8+ T cells are a type of immune cell that can be directly lethal to tumor cells. However, their tumor killing capabilities can be inhibited by checkpoint molecules. During the last decade, the development of medications that block these checkpoint molecules has revolutionized treatment for some cancer types and indications for use continue to grow. As usage of immunotherapy increases, toxicities and adverse events unique to immunotherapy are becoming more prevalent. Here, we review the commonly targeted inhibitory molecules along with their food and drug administration-approved indications in various cancer therapeutic regimens, immunotherapy-related toxicities, and how this may impact surgical planning.
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Affiliation(s)
- Xavier L Baldwin
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Philip M Spanheimer
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Stephanie Downs-Canner
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, New York.
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16
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Aschauer J, Donner R, Lammer J, Schmidinger G. Bilateral corneal perforation in Ipilimumab/Nivolumab - associated peripheral ulcerative keratitis. Am J Ophthalmol Case Rep 2022; 28:101686. [PMID: 36072439 PMCID: PMC9442328 DOI: 10.1016/j.ajoc.2022.101686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/10/2022] [Accepted: 08/13/2022] [Indexed: 12/09/2022] Open
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17
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Mazharuddin AA, Whyte AT, Gombos DS, Patel N, Razmandi A, Chaudhry AL, Al-Zubidi NS. Highlights on Ocular Toxicity of Immune Checkpoint Inhibitors at a US Tertiary Cancer Center. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2022; 5:98-104. [PMID: 36483585 PMCID: PMC9714419 DOI: 10.36401/jipo-22-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/22/2022] [Accepted: 09/09/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have improved prognosis in advanced malignancies; however, they may be associated with extensive ocular immune-related adverse events (irAEs) that are sight threatening. Our study aimed to identify the presentation, characteristics, management, and clinical outcomes of ocular irAEs. METHODS In this retrospective, observational case series, we reviewed the medical records of 1280 patients at a large US tertiary cancer center between 2010 and 2020. RESULTS We identified 130 patients who presented with ocular irAEs (10%) with 69 males (53%) and 61 females (47%). The mean time to toxicity was 6.1 months. Adverse events include corneal toxicity (31%), neuro-ophthalmic (14%), uveitis and scleritis (13%), retinopathy (13%), periocular disorders (11%), and others. IrAEs occurred most frequently with nivolumab (26%). Most ocular irAEs were treated with topical therapy. Advanced cases required systemic corticosteroids and even cessation of ICIs. CONCLUSION Our cohort is a large case series highlighting the increased potential of ocular toxicity associated with ICIs. Prompt recognition and management of ocular irAEs can minimize their effect.
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Affiliation(s)
- Anam A. Mazharuddin
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
| | - Andrew T. Whyte
- Department of Head and Neck Surgery, Section of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dan S. Gombos
- Department of Head and Neck Surgery, Section of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nimisha Patel
- Department of Head and Neck Surgery, Section of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Azadeh Razmandi
- Department of Head and Neck Surgery, Section of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amina L. Chaudhry
- Department of Head and Neck Surgery, Section of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nagham S. Al-Zubidi
- Department of Head and Neck Surgery, Section of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- Department of Ophthalmology, Weill Cornell Medicine, New York, NY, USA
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18
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Borges Silva A, Figueira J, Fonseca C. A Pigmented Epiretinal Membrane in the Eighth Decade of Life. JAMA Ophthalmol 2022; 140:2797388. [PMID: 36227602 DOI: 10.1001/jamaophthalmol.2022.3949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A 75-year-old woman who presented with decreased visual acuity and metamorphopsia in the right eye was referred for further evaluation of a pigmented epiretinal membrane. She had a history of cutaneous nodular melanoma in the right arm. What would you do next?
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Affiliation(s)
- André Borges Silva
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - João Figueira
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Cristina Fonseca
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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19
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Nguyen CB, Su CT, Morgan M, Alva AS. Case report: Immune-mediated meibomian gland dysfunction following pembrolizumab therapy for advanced urothelial carcinoma. Front Oncol 2022; 12:1000023. [PMID: 36276085 PMCID: PMC9582237 DOI: 10.3389/fonc.2022.1000023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Ocular immune-related adverse events are a relatively rare complication of immune checkpoint inhibitors. Common ocular toxicities range from dry eyes to inflammatory uveitis and ocular myasthenia gravis. Here, we present the case of a 55-year-old woman with recurrent urothelial carcinoma of the ureter after initially being managed with neoadjuvant cisplatin-based chemotherapy and surgical resection. She was treated with pembrolizumab which was complicated by immune-mediated pneumonitis after the eighth cycle, which was managed with a prolonged steroid course. The patient also developed red eyes along with recurrent styes. Eye examination revealed decreased tear breakup time, expression of thick and turbid meibum, and meibomian gland atrophy on infrared meibography. The patient was diagnosed with suspected immune-mediated meibomian gland dysfunction (MGD) as a result of pembrolizumab, a previously unreported complication of immunotherapy. The goal of MGD therapy is to stabilize the tear film and minimize evaporation with lipid-based lubricants and other conservative treatments.
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20
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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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21
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O'Cearbhaill RE, Clark L, Eskander RN, Gaillard S, Moroney J, Pereira E, Pothuri B. Immunotherapy toxicities: An SGO clinical practice statement. Gynecol Oncol 2022; 166:25-35. [PMID: 35597686 PMCID: PMC10566626 DOI: 10.1016/j.ygyno.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 11/23/2022]
Affiliation(s)
- R E O'Cearbhaill
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, USA.
| | - L Clark
- University of North Carolina, Chapel Hill, NC, USA
| | - R N Eskander
- University of California, San Diego, Moores Cancer Center, La Jolla, CA, USA
| | - S Gaillard
- Johns Hopkins University, Baltimore, MD, USA
| | - J Moroney
- University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | | | - B Pothuri
- New York University School of Medicine, New York, NY, USA
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22
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Aschauer J, Donner R, Lammer J, Schmidinger G. Atezolizumab induced immune-related adverse event mimicking conjunctival metastatic disease. Am J Ophthalmol Case Rep 2022; 26:101489. [PMID: 35313472 PMCID: PMC8933674 DOI: 10.1016/j.ajoc.2022.101489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 12/20/2022] Open
Affiliation(s)
- Julia Aschauer
- Corresponding author. Department of Ophthalmology and Optometry Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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23
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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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24
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Vaddepally R, Doddamani R, Sodavarapu S, Madam NR, Katkar R, Kutadi AP, Mathew N, Garje R, Chandra AB. Review of Immune-Related Adverse Events (irAEs) in Non-Small-Cell Lung Cancer (NSCLC)—Their Incidence, Management, Multiorgan irAEs, and Rechallenge. Biomedicines 2022; 10:biomedicines10040790. [PMID: 35453540 PMCID: PMC9027181 DOI: 10.3390/biomedicines10040790] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 11/16/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced malignancies, including non-small cell lung cancer (NSCLC). These agents have improved clinical outcomes and have become quite an attractive alternative alone or combined with other treatments. Although ICIs are tolerated better, they also lead to unique toxicities, termed immune-related adverse events (irAEs). A reconstituted immune system may lead to dysregulation in normal immune self-tolerance and cause inflammatory side effects (irAEs). Although any organ system can be affected, immune-related adverse events most commonly involve the gastrointestinal tract, endocrine glands, skin, and liver. They can occur anytime during the treatment course and rarely even after completion. Owen and colleagues showed that approximately 30% of patients with NSCLC treated with ICIs develop irAEs. Kichenadasse et al. conducted a thorough evaluation of multiorgan irAEs, which is of particular interest because information regarding these types of irAEs is currently sparse. It is important to delineate between infectious etiologies and symptom progression during the management of irAEs. Close consultation with disease-specific subspecialties is encouraged. Corticosteroids are the mainstay of treatment of most irAEs. Early intervention with corticosteroids is crucial in the general management of immune-mediated toxicity. Grade 1–2 irAEs can be closely monitored; hypothyroidism and other endocrine irAEs may be treated with hormone supplementation without the need for corticosteroid therapy. Moderate- to high-dose steroids and other additional immunosuppressants such as tocilizumab and cyclophosphamide might be required in severe, grade 3–4 cases. Recently, increasing research on irAEs after immunotherapy rechallenge has garnered much attention. Dolladille and colleagues assessed the safety in patients with cancer who resumed therapy with the same ICIs and found that rechallenge was associated with about 25–30% of the same irAEs experienced previously (4). However, such data should be carefully considered. Further pooled analyses may be required before we conclude about ICIs’ safety in rechallenge.
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Affiliation(s)
- Raju Vaddepally
- Yuma Regional Medical Center, 2400 S Avenue A, Yuma, AZ 85364, USA; (N.R.M.); (R.K.); (A.P.K.); (N.M.); (A.B.C.)
- Correspondence:
| | - Rajiv Doddamani
- Slidell Memorial Hospital, 1001 Gause Blvd, Slidell, LA 70458, USA;
| | - Soujanya Sodavarapu
- San Joaquin General Hospital, 500 W Hospital Road, French Camp, CA 95231, USA;
| | - Narasa Raju Madam
- Yuma Regional Medical Center, 2400 S Avenue A, Yuma, AZ 85364, USA; (N.R.M.); (R.K.); (A.P.K.); (N.M.); (A.B.C.)
| | - Rujuta Katkar
- Yuma Regional Medical Center, 2400 S Avenue A, Yuma, AZ 85364, USA; (N.R.M.); (R.K.); (A.P.K.); (N.M.); (A.B.C.)
| | - Anupama P. Kutadi
- Yuma Regional Medical Center, 2400 S Avenue A, Yuma, AZ 85364, USA; (N.R.M.); (R.K.); (A.P.K.); (N.M.); (A.B.C.)
| | - Nibu Mathew
- Yuma Regional Medical Center, 2400 S Avenue A, Yuma, AZ 85364, USA; (N.R.M.); (R.K.); (A.P.K.); (N.M.); (A.B.C.)
| | - Rohan Garje
- Department of Internal Medicine-Hematology/Oncology, University of Iowa, Iowa, IA 52242, USA;
| | - Abhinav B. Chandra
- Yuma Regional Medical Center, 2400 S Avenue A, Yuma, AZ 85364, USA; (N.R.M.); (R.K.); (A.P.K.); (N.M.); (A.B.C.)
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Al-Zubidi N, Page JC, Gombos DS, Srivastava A, Appelbaum E, Gidley PW, Chambers MS, Nader ME. Immune-Related Oral, Otologic, and Ocular Adverse Events. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1342:399-416. [PMID: 34972977 DOI: 10.1007/978-3-030-79308-1_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emerging immunotherapeutic agents, including immune checkpoint inhibitors targeting cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed cell death protein ligand 1 (PD-L1), have revolutionized cancer treatment. The first immune checkpoint inhibitor (ICI) ipilimumab, an anti-CTLA-4, was approved in 2011. Since then, the US Food and Drug Administration (FDA) has approved more than half a dozen immune checkpoint inhibitors to treat various malignancies. These agents are part of a broader class of chemotherapy agents termed immunotherapy, which selectively target different steps in the immune response cascade to upregulate the body's normal response to cancer. While the effects of traditional chemotherapy are well known, the toxicity profile of emerging immune therapies is not fully elucidated. They have been associated with atypical side effects labeled collectively as immune-related adverse events (irAEs).
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Affiliation(s)
- Nagham Al-Zubidi
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Cody Page
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dan S Gombos
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Akanksha Srivastava
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric Appelbaum
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul W Gidley
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark S Chambers
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marc-Elie Nader
- Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Toxicitatea oculară a terapiilor biologice în tumorile solide. ONCOLOG-HEMATOLOG.RO 2022. [DOI: 10.26416/onhe.61.4.2022.7416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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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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28
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Shen P, Deng X, Hu Z, Chen Z, Huang Y, Wang K, Qin K, Huang Y, Ba X, Yan J, Han L, Tu S. Rheumatic Manifestations and Diseases From Immune Checkpoint Inhibitors in Cancer Immunotherapy. Front Med (Lausanne) 2021; 8:762247. [PMID: 34805229 PMCID: PMC8599930 DOI: 10.3389/fmed.2021.762247] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/13/2021] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs), which can enhance antitumor immunity and inhibit cancer growth, have revolutionized the treatment of multiple cancers and dramatically decreased mortality. However, treatment with ICIs is directly associated with immune-related adverse events (irAEs) because of inflammation in off-target organs and autoimmunity resulting from non-specific immune activation. These irAEs can cause rheumatic diseases and manifestations such as inflammatory arthritis, polymyalgia rheumatica, myositis, vasculitis, Sicca and Sjogen's syndrome, and systemic lupus erythematosus. Early diagnosis and treatment of these adverse events will improve outcomes and quality of life for cancer patients. The treatment of rheumatic diseases induced by ICIs requires multidisciplinary cooperation among physicians. Furthermore, the underlying mechanisms are not fully understood and it is difficult to predict and evaluate these side effects precisely. In this review, we summarize available studies and findings about rheumatic irAEs, focusing mainly on the clinical manifestations, epidemiology, possible mechanisms, and guiding principles for treating these irAEs.
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Affiliation(s)
- Pan Shen
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xuan Deng
- Department of Nephrology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhishuo Hu
- Department of Emergency, Wuhan No.1 Hospital, Wuhan, China
| | - Zhe Chen
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yao Huang
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ke Wang
- Department of Integrated Traditional Chinese and Western Medicine, The Central Hospital of Wuhan, Wuhan, China
| | - Kai Qin
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ying Huang
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xin Ba
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jiahui Yan
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Liang Han
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Shenghao Tu
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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Fardeau C, Bencheqroun M, Levy A, Bonnin S, Ferchaud MA, Fardeau L, Coscas F, Bodaghi B, Lebrun-Vignes B. Uveitis associated with cancer immunotherapy: long-term outcomes. Immunotherapy 2021; 13:1465-1481. [PMID: 34709074 DOI: 10.2217/imt-2021-0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: We report the long-term outcome of uveitis associated with cancer immunotherapy (CIT). Methods: This retrospective review included serial patients with CIT-associated uveitis treated using various regimen. Results: Eight patients treated with rituximab (anti-CD20), nivolumab (anti-PD-1), ipilimumab (anti-CTLA-4), vemurafenib and dabrafenib (anti-BRAF), trametinib (anti-MEK) and ibritunib showed uveitis with hypopion (one patient), macular edema (five patients) and choroiditis (two patients). Various regimens of corticosteroid therapy showed a favorable ophthalmological outcome, whether the CIT was continuing or suspended. Conclusion: Local corticosteroid injections in combination with CIT could be suggested as a first-line treatment. This could help to preserve the quality of life without threatening the vital prognosis.
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Affiliation(s)
- Christine Fardeau
- Department of Ophthalmology, Reference Center for Rare Diseases, La Pitié-Salpêtrière Hospital, Paris-Sorbonne University, Paris, 75013, France
| | - Mehdi Bencheqroun
- Department of Ophthalmology, Reference Center for Rare Diseases, La Pitié-Salpêtrière Hospital, Paris-Sorbonne University, Paris, 75013, France
| | - Arielle Levy
- Department of Ophthalmology, Reference Center for Rare Diseases, La Pitié-Salpêtrière Hospital, Paris-Sorbonne University, Paris, 75013, France
| | - Sophie Bonnin
- Department of Ophthalmology, Reference Center for Rare Diseases, La Pitié-Salpêtrière Hospital, Paris-Sorbonne University, Paris, 75013, France.,Department of Ophthalmology, Fondation Rothschild, Université de Paris, Paris, 75019, France
| | - Marie-Adélaïde Ferchaud
- Department of Ophthalmology, Reference Center for Rare Diseases, La Pitié-Salpêtrière Hospital, Paris-Sorbonne University, Paris, 75013, France
| | - Leila Fardeau
- Institut de Démographie, Université Paris 1 - Panthéon Sorbonne, Paris, France
| | - Florence Coscas
- Centre Ophtalmologique de l'Odéon, Agora Académie, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, Reference Center for Rare Diseases, La Pitié-Salpêtrière Hospital, Paris-Sorbonne University, Paris, 75013, France
| | - Bénédicte Lebrun-Vignes
- Department of Pharmacovigilance, La Pitié-Salpêtrière Hospital, Paris-Sorbonne University, Paris, 75013, France
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Elwood KF, Pulido JS, Ghafoori SD, Harper CA, Wong RW. CHOROIDAL NEOVASCULARIZATION AND CHORIORETINAL ATROPHY IN A PATIENT WITH MELANOMA-ASSOCIATED RETINOPATHY AFTER IPILIMUMAB/NIVOLUMAB COMBINATION THERAPY. Retin Cases Brief Rep 2021; 15:514-518. [PMID: 31246886 DOI: 10.1097/icb.0000000000000882] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE To describe a case of choroidal neovascularization (CNV) and chorioretinal scarring in a patient with melanoma-associated retinopathy after ipilimumab/nivolumab combination immune therapy for malignant melanoma. METHODS Retrospective case report with fundus photography, fluorescein angiography, optical coherence tomography, and electroretinography. RESULTS A 65-year-old woman presented with symptoms of photopsia and visual field loss. She had previously undergone ipilimumab/nivolumab combination chemotherapy treatment for malignant melanoma 14 months earlier coinciding with the onset of her visual symptoms. Fundus photography showed bilateral atrophic chorioretinal lesions and peripheral retinal pigment epithelial changes. Fluorescein angiography revealed retinovascular leakage in both eyes with CNV in the right eye. Optical coherence tomography showed a pigment epithelial detachment with subretinal fluid and subretinal hyperreflective material consistent with occult CNV. Visual field testing showed generalized visual field loss in both eyes. Bloodwork discovered an elevated angiotensin-converting enzyme. Electroretinography revealed abnormal peripheral rod and cone function with impairment of the photoreceptor and inner nuclear layer. Serum Western blot was positive for 60 kDa antiretinal autoantibody. After a single bevacizumab injection in the right eye, CNV resolved and visual acuity improved from 20/50 before the injection to 20/25 3 months after the injection. Visual acuity in the left eye deteriorated for months to counting fingers but then improved to 20/100 on follow-up examinations. CONCLUSION Ipilimumab and nivolumab have been associated with immune-related ocular adverse effects. We report a case of combination therapy presenting with chorioretinal scarring and subsequent CNV in a patient with melanoma-associated retinopathy, a rare yet important adverse effect.
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Affiliation(s)
- Kevin F Elwood
- Department of Ophthalmology, Dell Medical School, University of Texas, Austin
| | - Jose S Pulido
- Departments of Ophthalmology, and
- Molecular Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Shelley Day Ghafoori
- Department of Ophthalmology, Dell Medical School, University of Texas, Austin
- Austin Retina Associates, Austin, Texas
| | - C Armitage Harper
- Department of Ophthalmology, Dell Medical School, University of Texas, Austin
- Austin Retina Associates, Austin, Texas
| | - Robert W Wong
- Department of Ophthalmology, Dell Medical School, University of Texas, Austin
- Austin Retina Associates, Austin, Texas
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31
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Yildirim OA, Poyraz K, Erdur E, Can C, Gundogan C, Guzel Y, Etem H, Kömek H. Nivolumab-Related Dry Mouth and Dry Eye: Cross-Sectional Study. Cancer Invest 2021; 39:797-807. [PMID: 34415812 DOI: 10.1080/07357907.2021.1971241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
To evaluate ICIs related dry eye and dry mouth in nivolumab therapy, 24 patients receiving nivolumab (group 1), 30 patients in remission without treatment for 6 months (group 2), 30 healthy participants (group 3) were cross-sectionally examined. Schirmer's 1, 2, TSH blood tests, serological analysis, salivary flow scintigraphy and minor-salivary gland biopsy were performed. Schirmer's tests were performed with anesthetic (1) and without anesthetic (2). Schirmer's scores were lower in group 1 with more frequent reduced tear production (p < 0.001). TSH levels negatively correlated with Schirmer's scores. Functional insufficiency was detected by salivary flow scintigraphy in 7 out of 10 patients with Schirmer's test positivity. In Schirmer's positive patients, lymphocytic sialadenitis was confirmed in 4 patients (focus score > 1) and CD4 T lymphocyte precipitation was observed in 6 patients. Nivolumab therapy may be associated with ICIs related immune sicca.
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Affiliation(s)
- Ozgen Ahmet Yildirim
- Department of Internal Medicine, Division of Medical Oncology, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Kerem Poyraz
- Department of Radiation Oncology, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Erkan Erdur
- Department of Internal Medicine, Division of Medical Oncology, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Canan Can
- Department of Nuclear Medicine, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Cihan Gundogan
- Department of Nuclear Medicine, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Yunus Guzel
- Department of Nuclear Medicine, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Hülya Etem
- Department of Pathology, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Halil Kömek
- Department of Nuclear Medicine, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
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32
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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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33
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Brahmer JR, Abu-Sbeih H, Ascierto PA, Brufsky J, Cappelli LC, Cortazar FB, Gerber DE, Hamad L, Hansen E, Johnson DB, Lacouture ME, Masters GA, Naidoo J, Nanni M, Perales MA, Puzanov I, Santomasso BD, Shanbhag SP, Sharma R, Skondra D, Sosman JA, Turner M, Ernstoff MS. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse events. J Immunother Cancer 2021; 9:e002435. [PMID: 34172516 PMCID: PMC8237720 DOI: 10.1136/jitc-2021-002435] [Citation(s) in RCA: 329] [Impact Index Per Article: 109.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are the standard of care for the treatment of several cancers. While these immunotherapies have improved patient outcomes in many clinical settings, they bring accompanying risks of toxicity, specifically immune-related adverse events (irAEs). There is a need for clear, effective guidelines for the management of irAEs during ICI treatment, motivating the Society for Immunotherapy of Cancer (SITC) to convene an expert panel to develop a clinical practice guideline. The panel discussed the recognition and management of single and combination ICI irAEs and ultimately developed evidence- and consensus-based recommendations to assist medical professionals in clinical decision-making and to improve outcomes for patients.
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Affiliation(s)
- Julie R Brahmer
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Hamzah Abu-Sbeih
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Paolo Antonio Ascierto
- Unit of Melanoma Cancer Immunotherapy and Innovative Therapy, National Tumour Institute IRCCS Fondazione 'G. Pascale', Napoli, Italy
| | - Jill Brufsky
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura C Cappelli
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frank B Cortazar
- Massachusetts General Hospital, Boston, Massachusetts, USA
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - David E Gerber
- Department of Hematology and Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lamya Hamad
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Eric Hansen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Mario E Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory A Masters
- Department of Medicine, Helen F. Graham Cancer Center, Newark, Delaware, USA
| | - Jarushka Naidoo
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
- Department of Oncology, Beaumont Hospital Dublin, The Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Michele Nanni
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Satish P Shanbhag
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Cancer Specialist of North Florida, Fleming Island, Florida, USA
| | - Rajeev Sharma
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Dimitra Skondra
- Department of Ophthalmology and Visual Science, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jeffrey A Sosman
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Medical Center, Chicago, Illinois, USA
| | - Michelle Turner
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Marc S Ernstoff
- Division of Cancer Treatment & Diagnosis, National Cancer Institute, Rockville, Maryland, USA
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34
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Retinal toxicities of systemic anticancer drugs. Surv Ophthalmol 2021; 67:97-148. [PMID: 34048859 DOI: 10.1016/j.survophthal.2021.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 01/07/2023]
Abstract
Newer anticancer drugs have revolutionized cancer treatment in the last decade, but conventional chemotherapy still occupies a central position in many cancers, with combination therapy and newer methods of delivery increasing their efficacy while minimizing toxicities. We discuss the retinal toxicities of anticancer drugs with an emphasis on the mechanism of toxicity. Uveitis is seen with the use of v-raf murine sarcoma viral oncogene homolog B editing anticancer inhibitors as well as immunotherapy. Most of the cases are mild with only anterior uveitis, but severe cases of posterior uveitis, panuveitis, and Vogt-Koyanagi-Harada-like disease may also occur. In the retina, a transient neurosensory detachment is observed in almost all patients on mitogen-activated protein kinase kinase (MEK) inhibitors. Microvasculopathy is often seen with interferon α, but vascular occlusion is a more serious toxicity caused by interferon α and MEK inhibitors. Crystalline retinopathy with or without macular edema may occur with tamoxifen; however, even asymptomatic patients may develop cavitatory spaces seen on optical coherence tomography. A unique macular edema with angiographic silence is characteristic of taxanes. Delayed dark adaptation has been observed with fenretinide. Interestingly, this drug is finding potential application in Stargardt disease and age-related macular degeneration.
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35
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Risk of Ophthalmic Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Regimens: A Systematic Review and Meta-analysis. Ocul Immunol Inflamm 2021; 30:1449-1459. [PMID: 33970759 DOI: 10.1080/09273948.2021.1890133] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Immune checkpoint inhibitors (ICIs) -induced adverse events (AEs) have been reported affecting almost all human organs. However, studies about ocular AEs are few. A meta-analysis was performed to evaluate the risks of ICI-related ophthalmic AEs compare to chemotherapy.Methods: Eligible studies were selected from phase II/III randomized controlled trials investigating ICIs. The data were analyzed by R software and Stata.Results: Odds ratio of treatment-related AE (trAEs) and nonspecific ophthalmic trAEs (NS-trAEs) were lower for PD-1/PD-L1 inhibitors than chemotherapy (OR 0.44, p < .05; OR 0.28, p < .001; OR 0.18, p < . 05; OR: 0.18, p < .001respectively). Compared with monotherapy, PD-1 plus CTLA-4 inhibitors increased the risks of immune-related AEs (irAEs) (OR 4.52, p < .01); ICIs plus chemotherapy increased the risks of trAEs and irAEs (OR 2.82, p < .001; OR 3.63, p < .05 respectively).Conclusions: PD-L1/PD-1 inhibitors had lower risks of trAEs and NS-trAEs than chemotherapy; Compared with monotherapy, combination therapy had higher risks of ophthalmic trAEs and irAEs.Abbreviation PD-1: programmed cell death protein 1; PD-L1: programmed cell death protein ligand 1; CTLA-4: cytotoxic T-lymphocyte-associated protein 4; ICI: immune checkpoint inhibitor; AE: adverse event; trAE: treatment-related adverse event;irAE: immune-related adverse events; NS-trAE: nonspecific ophthalmic treatment-related adverse event; RCT: randomized controlled trials; PFS: progression-free survival; OS: overall survival; ORR: objective response rate; MM: melanoma; NSCLC: non-small cell lung cancer; SCLC: small cell lung cancer; HNSCC: head-neck squamous cell carcinoma; PICOL: patient, intervention, comparison, and outcome; Versus: VS; Chem: chemotherapy; 95%CI: 95% confidence interval; FEM: fixed-effects model; REM: random-effects model; NA: not applicable; MeSH: medical subject heading.
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Braun D, Getahun D, Chiu VY, Coleman AL, Holland GN, Yu F, Gordon LK, Sun MM. Population-Based Frequency of Ophthalmic Adverse Events in Melanoma, Other Cancers, and After Immune Checkpoint Inhibitor Treatment. Am J Ophthalmol 2021; 224:282-291. [PMID: 33359682 DOI: 10.1016/j.ajo.2020.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE To examine the frequency of ophthalmic immune-related adverse events (OirAEs) in melanoma, other cancers, and after immune checkpoint inhibitor (ICI) treatment. DESIGN Retrospective clinical cohort study. METHODS This study identified patients diagnosed with OirAEs between January 1, 2011, and December 31, 2018, in the Kaiser Permanente Southern California electronic health records. The primary exposures of interest were prior initiation of ICIs and underlying cancer diagnosis. Risk-adjusted prevalence of OirAEs was evaluated in patients with melanoma, with nonmelanoma cancer, and without cancer. The 1-year incidence of OirAEs and recurrence of prior ophthalmic disease were identified in ICI-receiving patients with melanoma and nonmelanoma. RESULTS Among 4,695,669 unique patients identified, 9.9% had a cancer diagnosis, of whom 2.8% had a diagnosis of melanoma. Overall prevalence for uveitis and selected neuro-ophthalmic diagnoses was 341.8/100,000 patient-years in patients with melanoma and 369.6/100,000 patient-years in patients with nonmelanoma cancer regardless of ICI treatment, compared with 142.2/100,000 patient-years in patients without cancer. A total of 2,911 unique patients received ICI therapy. Compared with patients with nonmelanoma cancer, patients with melanoma on any ICI had elevated 1-year incidence rates of uveitis (1.2% vs 0.2%; risk-adjusted odds ratio, 6.45). High 1-year recurrence rates for uveitis in ICI patients with a prior uveitis history were also observed. CONCLUSIONS The prevalence of all OirAEs was substantially higher in patients with cancer, with ICI-related uveitis risk specifically increased in patients with melanoma compared with patients with nonmelanoma cancer. Evidence-based guidelines for ophthalmic monitoring of patients undergoing ICI treatment may require different risk stratifications based on underlying cancer diagnosis, specific ICI used, and prior history of uveitis.
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Affiliation(s)
- David Braun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA; Department of Pediatrics, Kaiser Permanente Panorama City, Panorama City, California, USA
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Vicki Y Chiu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Anne L Coleman
- UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Jonathan and Karin Fielding School of Public Health, UCLA, Los Angeles, California, USA
| | - Gary N Holland
- UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Fei Yu
- UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Jonathan and Karin Fielding School of Public Health, UCLA, Los Angeles, California, USA
| | - Lynn K Gordon
- UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Michel M Sun
- UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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Dow ER, Hou K, Ransome S, Abbassi S, Tsui E. Posterior Uveitis Associated with Cemiplimab. Ocul Immunol Inflamm 2021; 30:1211-1213. [PMID: 33793370 DOI: 10.1080/09273948.2021.1872649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE The immune checkpoint inhibitors (ICPIs) comprise a class of oncologic immunotherapies. The most recent US Food and Drug Administration-approved ICPI is cemiplimab (Libtayo®). Cemiplimab, like the other ICPIs, blocks checkpoint receptors in order to disinhibit T-cells so that they may detect and eliminate tumor cells. Consequently, treatment with ICPIs is associated with immune-related adverse events including uveitis. METHODS Case report. RESULTS A 63-year-old man with a history of metastatic squamous cell carcinoma developed blurry vision 3 months after starting treatment with cemiplimab. The patient was found to have posterior uveitis with retinal vasculitis that was successfully controlled with discontinuation of the medication as well as treatment with local and systemic steroids. CONCLUSION Similar to other ICPIs, uveitis may be associated with cemiplimab. In the setting of posterior uveitis, treatment may require cessation of cemiplimab and intensive steroid treatment.
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Affiliation(s)
- Eliot R Dow
- Stein Eye Institute, David Geffen of Medicine at UCLA, Los Angeles, California, USA
| | - Kirk Hou
- Stein Eye Institute, David Geffen of Medicine at UCLA, Los Angeles, California, USA
| | - Susan Ransome
- Stein Eye Institute, David Geffen of Medicine at UCLA, Los Angeles, California, USA
| | - Sam Abbassi
- Southern California Desert Retina Consultants, Palm Desert, California, USA
| | - Edmund Tsui
- Stein Eye Institute, David Geffen of Medicine at UCLA, Los Angeles, California, USA
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Abstract
The proliferation of targeted anticancer agents over the last two decades has revolutionized cancer treatment and improved survival in many previously refractory malignancies. However, many agents are associated with characteristic ophthalmic adverse effects. It is important that ophthalmologists recognize and maintain a high index of suspicion for these side effects in patients on targeted therapy. Most ophthalmic adverse effects can be treated with specific ocular therapy without discontinuation of cancer treatment, although it is important to be aware of the life-threatening and vision-threatening circumstances that would require therapy cessation in conjunction with the patient's oncologist. This review aims to summarize the ophthalmic adverse effects of targeted and hormonal anticancer agents and briefly describe their management.
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Kim KW, Kusuhara S, Tachihara M, Mimura C, Matsumiya W, Nakamura M. A case of panuveitis and retinal vasculitis associated with pembrolizumab therapy for metastatic lung cancer. Am J Ophthalmol Case Rep 2021; 22:101072. [PMID: 33796799 PMCID: PMC7995477 DOI: 10.1016/j.ajoc.2021.101072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 02/02/2021] [Accepted: 03/07/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To report a case of panuveitis and retinal vasculitis associated with pembrolizumab therapy for metastatic lung cancer. Observations A 71-year-old man, who was diagnosed with metastatic lung cancer (squamous cell carcinoma), presented with blurry vision 2 weeks after the initiation of pembrolizumab monotherapy. His best-corrected visual acuity (BCVA) was 20/20 OU, and slitlamp examination revealed fine keratic precipitates, anterior chamber cells (1+) and flare (1+) in both eyes. Dilated fundus examination showed no remarkable finding in the right eye and vitreous haze (2+), perivascular exudates, and vessel sheathing in the left eye. Fluorescence angiography demonstrated dye leakage from the optic disc and both retinal arteries and veins extending from the posterior to the peripheral retina in both eyes. The patient was diagnosed with panuveitis and retinal vasculitis as Grade 3 immune-related adverse event (irAE). Pembrolizumab was discontinued and oral prednisone 70mg/day was given for 1 week. The dose was reduced to 30mg/day for the next 3 weeks and was then stopped. One month after the treatment, intraocular inflammation became quiescent. With a good response to the treatment of irAE, pembrolizumab was restarted. Recurrence of ocular inflammation occurred over the next 1.5 years, but all of which were successfully treated with sub-Tenon's injection of triamcinolone acetonide (STTA). The patient maintained BCVA of 30/20 OU at the latest visit. Conclusions and importance We showed a case of retinal vasculitis occurred as an irAE of pembrolizumab for metastatic lung cancer. Retinal vasculitis was well managed with transient pembrolizumab discontinuation and oral corticosteroid therapy, and pembrolizumab was restarted with the aid of STTA. As ocular irAEs might be controlled by local corticosteroid therapy, the decision to continue immune checkpoint inhibitor therapy should be made on a case-by-case basis.
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Affiliation(s)
- Kyung Woo Kim
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sentaro Kusuhara
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
- Corresponding author. Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Motoko Tachihara
- Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Chihiro Mimura
- Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Wataru Matsumiya
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Makoto Nakamura
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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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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Bindiganavile SH, Bhat N, Lee AG, Gombos DS, Al-Zubidi N. Targeted Cancer Therapy and Its Ophthalmic Side Effects: A Review. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2021; 4:6-15. [PMID: 35664825 PMCID: PMC9161666 DOI: 10.36401/jipo-20-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/06/2020] [Indexed: 06/15/2023]
Abstract
Targeted cancer therapy agents are the latest development in cancer therapeutics. Although the spectrum of their use continues to expand, ocular side effects are frequently encountered with the use of cancer therapeutics. This review describes the ocular side effects of targeted cancer therapy agents.
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Affiliation(s)
| | - Nita Bhat
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Andrew G. Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- The Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, USA
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
- Texas A and M College of Medicine, Bryan, TX, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Section of Ophthalmology, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dan S. Gombos
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
- Section of Ophthalmology, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nagham Al-Zubidi
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- The Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, USA
- Section of Ophthalmology, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Dimitriou F, Urner-Bloch U, Eggenschwiler C, Mitsakakis N, Mangana J, Dummer R, Urner M. The association between immune checkpoint or BRAF/MEK inhibitor therapy and uveitis in patients with advanced cutaneous melanoma. Eur J Cancer 2021; 144:215-223. [PMID: 33373866 DOI: 10.1016/j.ejca.2020.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/20/2020] [Accepted: 11/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment with immune checkpoint and BRAF/MEK inhibitors has significantly improved the survival of patients with advanced cutaneous melanoma and other metastatic malignancies. Therapy-related uveitis is a rare ocular adverse event, which may potentially lead to legal blindness. The epidemiology of treatment-related uveitis is currently insufficiently known. PATIENTS AND METHODS In this cohort study, we asked whether exposure to either immune checkpoint or BRAF/MEK inhibitors was associated with a higher risk of developing uveitis compared with the general population. Based on a Bayesian framework, we estimated the probability of developing uveitis with a right-censored, exponential survival model using data from the Zurich Melanoma Registry. The registry included all adult patients treated for advanced cutaneous melanoma between January 2008 and December 2018 at the University Hospital of Zurich, Switzerland. RESULTS In total, 304 patients (64%) were treated with immune checkpoint and 186 patients (38%) with BRAF/MEK inhibitors. Median follow-up time was 74 days (interquartile range: 57-233 days). Eleven patients developed uveitis and 30 patients died. We estimated the probability of developing uveitis per year in the general population as 0.05% (95% credibility interval [CrI]: 0.02%-0.1%). Corresponding posterior probabilities of treatment-related uveitis were 3.48% (95% CrI: 0.93%-7.49%) and 5.04% (95% CrI: 2.07%-9.19%) for immune checkpoint or BRAF/MEK inhibitors (posterior probability for difference: 76%). CONCLUSIONS Immune checkpoint and particularly BRAF/MEK inhibitor therapies are associated with an increase in the risk of developing uveitis. Treatment-related uveitis is not associated with systemic adverse events of immune checkpoint or BRAF/MEK inhibitors.
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Affiliation(s)
- Florentia Dimitriou
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Ursula Urner-Bloch
- Private Ophthalmic Practice in Cooperation with the Skin Cancer Unit, University Hospital of Zurich, Zurich, Switzerland
| | | | - Nicholas Mitsakakis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Joanna Mangana
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.
| | - Martin Urner
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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Ramaekers A, Aspeslagh S, De Brucker N, Van Mierlo C, Ten Tusscher M, Schauwvlieghe PP, Termote K. Bilateral Corneal Perforation in a Patient Under Anti-PD1 Therapy. Cornea 2021; 40:245-247. [PMID: 33395118 DOI: 10.1097/ico.0000000000002490] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Immune checkpoint inhibition has improved the clinical outcomes for numerous patients with cancer. However, the downside is a whole new spectrum of immune-related adverse events. We report a 68-year-old man with a history of nonsmall cell lung cancer presenting with a spontaneous corneal perforation in the right eye after 22 cycles of pembrolizumab. In addition, a chronic central nonhealing epithelial defect developed after performing a penetrating keratoplasty. Treatment with autologous serum drops resulted in complete healing of the corneal ulcer, where other conventional therapies had no effect. One month after reinitiating pembrolizumab therapy, our patient presented again with a corneal perforation in the fellow eye. This case describes relapsing sterile ulcerations associated with pembrolizumab use and presents an unexpected cure.
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Affiliation(s)
| | | | | | | | | | | | - Karolien Termote
- Departments of Ophthalmology; and
- Medical Oncology, UZ Brussel - VUB, Brussels, Belgium
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Vishnevskia-Dai V, Rozner L, Berger R, Jaron Z, Elyashiv S, Markel G, Zloto O. Ocular side effects of novel anti-cancer biological therapies. Sci Rep 2021; 11:787. [PMID: 33436995 PMCID: PMC7803740 DOI: 10.1038/s41598-020-80898-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 12/11/2020] [Indexed: 12/26/2022] Open
Abstract
To examine the ocular side effects of selected biological anti-cancer therapies and the ocular and systemic prognosis of patients receiving them. We retrospectively reviewed all medical records of patients who received biological anti-cancer treatment from 1/2012 to 12/2017 and who were treated at our ocular oncology service. The following data was retrieved: primary malignancy, metastasis, type of biological therapy, ocular side effects, ophthalmic treatment, non-ocular side effects, and ocular and systemic disease prognoses. Twenty-two patients received biological therapies and reported ocular side effects. Eighteen patients (81.8%) had bilateral ocular side effects, including uveitis (40.9%), dry eye (22.7%), and central serous retinopathy (22.7%). One patient (4.5%) had central retinal artery occlusion (CRAO), and one patient (4.5%) had branch retinal vein occlusion (BRVO). At the end of follow-up, 6 patients (27.27%) had resolution of the ocular disease, 13 patients (59.09%) had stable ocular disease, and 3 patients (13.64%) had progression of the ocular disease. Visual acuity improved significantly at the end of follow-up compared to initial values. Eighteen patients (81.8%) were alive at study closure. Biological therapies can cause a wide range of ocular side effects ranging from dry eye symptoms to severe pathologies that may cause ocular morbidity and vision loss, such as uveitis, CRAO and BRVO. All patients receiving biological treatments should be screened by ophthalmologists before treatment, re-screened every 4–6 months during treatment, and again at the end of treatment. Patients on biological treatment who have ocular complaints should be urgently referred to ocular consultation for early identification and early intervention.
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Affiliation(s)
- Vicktoria Vishnevskia-Dai
- The Ocular Oncology Service, The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.
| | - Lihi Rozner
- The Ocular Oncology Service, The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Raanan Berger
- Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ziv Jaron
- The Ocular Oncology Service, The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Sivan Elyashiv
- The Ocular Oncology Service, The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Gal Markel
- Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofira Zloto
- The Ocular Oncology Service, The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
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Alba-Linero C, Alba E. Ocular side effects of checkpoint inhibitors. Surv Ophthalmol 2021; 66:951-959. [PMID: 33440195 DOI: 10.1016/j.survophthal.2021.01.001] [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: 09/24/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 01/06/2023]
Abstract
The incidence and impact of ocular side effects in patients treated with checkpoint inhibitors are not clearly defined. We reviewed prospective phase III clinical trials of checkpoint inhibitors applied in lung cancer, renal cell cancer, and melanoma. Case reports of the occurrence of ocular toxicities in patients receiving immune checkpoint inhibitors were also included. Of the 35 articles corresponding to phase III clinical trials with checkpoint inhibitors, ocular toxicity was described in four. Forty-six clinical cases of ocular toxicity after therapy with checkpoint inhibitors have been reported. The most frequently described ocular toxicities are uveitis, inflammatory orbital disease, and alterations of the ocular surface. Ocular toxicity is underestimated in checkpoint inhibitors clinical trials. Early ophthalmic examination and treatment with corticosteroids may improve the visual prognosis in these patients.
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Affiliation(s)
- Carmen Alba-Linero
- Hospital Regional Universitario Málaga, Málaga, Spain; Departamento Oftalmología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain.
| | - Emilio Alba
- Unidad de gestión clínica (UGI) Oncología Médica Hospital Regional y Universitario de Málaga, Instituto de Investigación de Biotecnología de Málaga (IBIMA), Málaga, Spain
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Abdalla Elsayed MEA, Kozak I. Pharmacologically induced uveitis. Surv Ophthalmol 2021; 66:781-801. [PMID: 33440194 DOI: 10.1016/j.survophthal.2021.01.003] [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] [Received: 07/22/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/26/2022]
Abstract
Treatments of numerous systemic and local diseases of different etiologies may be accompanied by an unwanted side effect in the form of uveitis. We inform readers about medications that have the potential to cause uveitis and analyze the strength of association of these medications with uveitis. Subsequently, cessation of medication or appropriate treatment can be individualized for each patient for the purpose of preventing further damage to tissue structure and function. Being aware of these associations, physicians may readily identify medications that may cause uveitis and avoid expensive and unnecessary clinical and laboratory testing.
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Affiliation(s)
| | - Igor Kozak
- Moorfields Eye Hospitals UAE, Abu Dhabi, United Arab Emirates.
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Spectrum and Management of Immune Related Adverse Events Due to Immune Checkpoint Inhibitors. Lung Cancer 2021. [DOI: 10.1007/978-3-030-74028-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Yeung SJ, Qdaisat A, Chaftari P, Lipe D, Merlin J, Rajha E, Wechsler A, Sandoval M, Viets J, Al‐Breiki A, Shah M, Pandey R, Kamal M, Khattab O, Toale K, Wattana M, Elsayem A, Gaeta S, Brock P, Reyes‐Gibby C, Alagappan K. Diagnosis and management of immune-related adverse effects of immune checkpoint therapy in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1637-1659. [PMID: 33392573 PMCID: PMC7771833 DOI: 10.1002/emp2.12209] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022] Open
Abstract
Rapid advances in cancer immunotherapy using immune checkpoint inhibitors have led to significantly improved survival. Rapid identification of the toxicity syndromes associated with these therapeutic agents is very important for emergency physicians because the population of patients diagnosed with cancer is increasing and cancer therapies including immune checkpoint inhibitors have become the first-line treatment for more and more types of cancer. The emergency medicine literature lags behind rapid advances in oncology, and oncology guidelines for rapid recognition and management of these emerging toxicity syndromes are not familiar to emergency physicians. In this review article, we discuss the clinical presentation and management of immune-related adverse effects during the critical first hours of emergency care. We also suggest a workflow for the recognition and treatment of emergencies arising from serious immune-related adverse effects, including but not limited to colitis, adrenal crisis, myocarditis, pneumonitis, myasthenic crisis, diabetic ketoacidosis, bullous pemphigus, and hemophagocytic lymphohistiocytosis. Rapid advances in cancer therapy are bringing new diagnostic and therapeutic challenges to emergency providers, and therefore it is crucial to raise awareness and provide guidelines for the management of new treatment-related toxicities.
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Affiliation(s)
- Sai‐Ching Jim Yeung
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Aiham Qdaisat
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Patrick Chaftari
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Demis Lipe
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jeffrey Merlin
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Eva Rajha
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Adriana Wechsler
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Marcelo Sandoval
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jayne Viets
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Aisha Al‐Breiki
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Mohsin Shah
- Center for Clinical Epidemiology and BiostatisticsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ramesh Pandey
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Mona Kamal
- Department of Symptom ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Clinical Oncology and Nuclear MedicineFaculty of MedicineAin Shams UniversityCairoEgypt
| | - Osama Khattab
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Katy Toale
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Monica Wattana
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ahmed Elsayem
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Susan Gaeta
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Patricia Brock
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Cielito Reyes‐Gibby
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Kumar Alagappan
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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Specenier P. Cost-effectiveness of nivolumab in advanced melanoma: a drug review. Expert Rev Pharmacoecon Outcomes Res 2020; 21:13-28. [PMID: 33225752 DOI: 10.1080/14737167.2021.1845144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: The immune checkpoint inhibitors, including nivolumab, and targeted agents have dramatically improved the outcome for patients with unresectable advanced melanoma. Areas covered: This is a narrative review of the published evidence on nivolumab in metastatic melanoma. Expert opinion: In ipilimumab pre-treated patients (CheckMate 037), nivolumab was associated with a higher response rate and a longer duration of response when compared to chemotherapy. In previously untreated patients, nivolumab improves survival when compared to chemotherapy (CheckMate 066) or to ipilimumab (CheckMate 067). The combination of nivolumab and ipilimumab also improves survival when compared to ipilimumab (CheckMate 067). CheckMate 067 was not designed to compare the nivolumab-ipilimumab combination to nivolumab alone. A modified regimen using a lower dose of ipilimumab in combination with standard dose nivolumab is better tolerated than nivolumab in combination with standard dose ipilimumab (CheckMate 511). In patients with previously untreated metastatic melanoma, the anti-PD-1 monoclonal antibodies nivolumab and pembrolizumab improve survival when compared to ipilimumab. Nivolumab is equally active in BRAF mutated and BRAF wild type melanoma. The optimal sequence of checkpoint inhibitors and BRAF/MEK inhibitors in BRAF mutated patients has not been established.
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Affiliation(s)
- Pol Specenier
- Department of Oncology, Antwerp University Hospital, Belgium and Faculty of Medicine and Health Sciences , Edegem, Wilrijk, Belgium
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