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Tetzlaff MT, Messina JL, Stein JE, Xu X, Amaria RN, Blank CU, van de Wiel BA, Ferguson PM, Rawson RV, Ross MI, Spillane AJ, Gershenwald JE, Saw RPM, van Akkooi ACJ, van Houdt WJ, Mitchell TC, Menzies AM, Long GV, Wargo JA, Davies MA, Prieto VG, Taube JM, Scolyer RA. Pathological assessment of resection specimens after neoadjuvant therapy for metastatic melanoma. Ann Oncol 2019; 29:1861-1868. [PMID: 29945191 DOI: 10.1093/annonc/mdy226] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Clinical trials have recently evaluated safety and efficacy of neoadjuvant therapy among patients with surgically resectable regional melanoma metastases. To capture informative prognostic data connected to pathological response in such trials, it is critical to standardize pathologic assessment and reporting of tumor response after this treatment. Methods The International Neoadjuvant Melanoma Consortium meetings in 2016 and 2017 assembled pathologists from academic centers to develop consensus guidelines for pathologic examination and reporting of surgical specimens from AJCC (8th edition) stage IIIB/C/D or oligometastatic stage IV melanoma patients treated with neoadjuvant-targeted or immune therapy. Patterns of pathologic response are provided context to inform these guidelines. Results Based on our collective experience and guided by efforts in well-established neoadjuvant settings like breast cancer, procedures directing handling of pre- and post-neoadjuvant therapy-treated melanoma specimens are provided to facilitate comparison of findings across different trials and centers. Definitions of pathologic response are provided together with guidelines for reporting and quantifying the extent of pathologic response. Finally, the spectrum of histopathologic responses observed following neoadjuvant-targeted and immune-checkpoint therapy is described and illustrated. Conclusions Standardizing pathologic evaluation of resected melanoma metastases following neoadjuvant-targeted or immune-checkpoint therapy allows more robust stratification of patient outcomes. This includes recognizing the spectrum of histopathologic response patterns to neoadjuvant therapy and a standard approach to grading pathologic responses. Such an approach will facilitate comparison of results across clinical trials and inform ongoing correlative studies into the mechanisms of response and resistance to agents applied in the neoadjuvant setting.
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Affiliation(s)
- M T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA.
| | - J L Messina
- Departments of Anatomic Pathology and Cutaneous Oncology, Moffitt Cancer Center, Tampa, USA
| | - J E Stein
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - X Xu
- Department of Pathology and Laboratory Medicine, The Hospital of the University of Pennsylvania, Philadelphia, USA
| | - R N Amaria
- Melanoma Medical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - C U Blank
- The Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - P M Ferguson
- Melanoma Institute of Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | - R V Rawson
- Melanoma Institute of Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | - M I Ross
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A J Spillane
- Melanoma Institute of Australia, The University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - J E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - R P M Saw
- Melanoma Institute of Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | | | - W J van Houdt
- The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - T C Mitchell
- Department of Medicine, The Hospital of the University of Pennsylvania, Philadelphia, USA
| | - A M Menzies
- Melanoma Institute of Australia, The University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - G V Long
- Melanoma Institute of Australia, The University of Sydney, Royal North Shore Hospital, Sydney, Australia
| | - J A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - M A Davies
- Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Melanoma Medical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Systems Biology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - V G Prieto
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Dermatology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J M Taube
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - R A Scolyer
- Melanoma Institute of Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
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Garcia CR, Jayswal R, Adams V, Anthony LB, Villano JL. Multiple sclerosis outcomes after cancer immunotherapy. Clin Transl Oncol 2019; 21:1336-1342. [PMID: 30788836 PMCID: PMC6702101 DOI: 10.1007/s12094-019-02060-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/05/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Neurological immune-related adverse events are a rare but potentially deadly complication after immune checkpoint inhibitor (ICI) treatment. As multiple sclerosis (MS) is an immune-mediated disease, it is unknown how ICI treatment may affect outcomes. METHODS We analyzed the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database for pembrolizumab, atezolizumab, nivolumab, ipilimumab, avelumab, and durvalumab 2 years prior their FDA approval until December 31, 2017, to include all cases with confirmed diagnosis/relapse of MS. We also included cases reported in the literature and a patient from our institution. RESULTS We identified 14 cases of MS with median age of presentation of 52 years. Indications for ICI included melanoma in 7 (36.36%) cases, non-small cell lung carcinoma in 2 (18.18%) cases, 1 case (9.09%) each of pleural mesothelioma, renal cell carcinoma, and colorectal cancer, and unreported in 2 (18.18%) cases. History of MS was confirmed in 8 (57.1%) cases. Median time to beginning of symptoms was 29 days with rapid disease progression; two patients died due to their relapse. Median time for symptom resolution was 8 weeks. Outcomes did not vary by comparing CTLA-4 and PD-1/PD-L1 inhibitors. CONCLUSIONS Reported MS relapses after ICI are rare, but the adverse events described include rapid neurologic progression and death. Larger and prospective studies are warranted to assess disability and long-term outcomes and outweigh the risks of starting immunotherapy in patients with MS.
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Affiliation(s)
- Catherine R. Garcia
- Departments of Internal Medicine (LBA, JLV), Neurology (JLV), Neurosurgery (JLV), Clinical Oncology Pharmacy (VA), Markey Cancer Center (CRG, RJ, VA, LBA, JLV), University of Kentucky
| | - Rani Jayswal
- Departments of Internal Medicine (LBA, JLV), Neurology (JLV), Neurosurgery (JLV), Clinical Oncology Pharmacy (VA), Markey Cancer Center (CRG, RJ, VA, LBA, JLV), University of Kentucky
| | - Val Adams
- Departments of Internal Medicine (LBA, JLV), Neurology (JLV), Neurosurgery (JLV), Clinical Oncology Pharmacy (VA), Markey Cancer Center (CRG, RJ, VA, LBA, JLV), University of Kentucky
| | - Lowell B Anthony
- Departments of Internal Medicine (LBA, JLV), Neurology (JLV), Neurosurgery (JLV), Clinical Oncology Pharmacy (VA), Markey Cancer Center (CRG, RJ, VA, LBA, JLV), University of Kentucky
| | - John L. Villano
- Departments of Internal Medicine (LBA, JLV), Neurology (JLV), Neurosurgery (JLV), Clinical Oncology Pharmacy (VA), Markey Cancer Center (CRG, RJ, VA, LBA, JLV), University of Kentucky
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Khunger A, Buchwald ZS, Lowe M, Khan MK, Delman KA, Tarhini AA. Neoadjuvant therapy of locally/regionally advanced melanoma. Ther Adv Med Oncol 2019; 11:1758835919866959. [PMID: 31391869 PMCID: PMC6669845 DOI: 10.1177/1758835919866959] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/08/2019] [Indexed: 11/18/2022] Open
Abstract
Locally/regionally advanced melanoma confers a major challenge in terms of surgical and medical management. Surgical treatment carries the risks of surgical morbidities and potential complications that could be lasting. In addition, these patients continue to have a high risk of relapse and death despite the use of standard adjuvant therapy. Neoadjuvant therapy has the potential to significantly improve the clinical outcome of these patients, particularly in this era of newer and effective targeted and immunotherapeutic agents. Previous neoadjuvant studies tested chemotherapy with temozolomide where the clinical activity was limited. Biochemotherapy (BCT) was tested in two studies in the neoadjuvant setting and showed high tumor response rates; however, BCT was ultimately abandoned following its failure to demonstrate survival benefits in randomized trials of metastatic disease. Success of immunotherapy and targeted therapy in prolonging the lives of patients with metastatic melanoma generated considerable interest to investigate these novel strategies in the adjuvant and neoadjuvant settings. A number of neoadjuvant targeted and immunotherapy studies have been completed in melanoma to date and have yielded promising clinical activity. Given these encouraging results, a number of studies with other molecularly targeted and immunotherapeutic agents and their combinations are ongoing in the neoadjuvant setting; long-term outcome data are eagerly awaited. Such studies also provide access to biospecimens before and during therapy, allowing for the conduct of biomarker and mechanistic studies that may have a significant impact in guiding adjuvant therapy choices and drug development.
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Affiliation(s)
- Arjun Khunger
- Department of Hematology and Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, OH, USA
| | - Zachary S. Buchwald
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Lowe
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohammad K. Khan
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Keith A. Delman
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ahmad A. Tarhini
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Winship Comprehensive Cancer Center, 1365 Clifton Rd Atlanta, GA 30322, USA
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Comparing and contrasting predictive biomarkers for immunotherapy and targeted therapy of NSCLC. Nat Rev Clin Oncol 2019; 16:341-355. [PMID: 30718843 DOI: 10.1038/s41571-019-0173-9] [Citation(s) in RCA: 327] [Impact Index Per Article: 65.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The era of personalized medicine for advanced-stage non-small-cell lung cancer (NSCLC) began when biomarker-based evidence of molecular pathway and/or oncogene addiction of the tumour became mandatory for the allocation of specific targeted therapies. More recently, the immunotherapy revolution, specifically, the development of immune-checkpoint inhibitors (ICIs), has dramatically altered the NSCLC treatment landscape. Herein, we compare and contrast the clinical development of immunotherapy and oncogene-directed therapy for NSCLC, focusing on the role of predictive biomarkers. Immunotherapy biomarkers are fundamentally different from oncogene biomarkers in that they are continuous rather than categorical (binary), spatially and temporally variable and reliant on multiple complex interactions rather than a single, dominant determinant. The performance of predictive biomarkers for ICIs might be improved by combining different markers to reduce the assumptive risks associated with each one. Novel combinations with chemotherapy and ICIs complicate biomarker discovery but do not decrease the value of the markers identified. Perfectly predictive biomarkers of benefit from immunotherapy are unlikely to be identified, although exclusionary biomarkers of minimal benefit or an unacceptable risk of toxicity might be feasible. The clinical adoption and applicability of such biomarkers might vary depending on line of treatment, the available therapeutic alternatives and health economic considerations.
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Macroangiopathy is a positive predictive factor for response to immunotherapy. Sci Rep 2019; 9:9728. [PMID: 31278360 PMCID: PMC6611819 DOI: 10.1038/s41598-019-46189-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 06/18/2019] [Indexed: 01/01/2023] Open
Abstract
Immunotherapies demand for predictive biomarkers to avoid unnecessary adverse effects and costs. Analytic morphomics is the technique to use body composition measures as imaging biomarkers for underlying pathophysiology to predict prognosis or outcome to therapy. We investigated different body composition measures to predict response to immunotherapy. This IRB approved retrospective analysis encompassed 147 patients with ipilimumab therapy. Degree of macroangiopathy was quantified with the newly defined total plaque index (TPI), i.e. the body height corrected sum of the soft and hard plaque volume of the infrarenal aorta on portalvenous CT scans. Furthermore, mean psoas density (MPD), different adipose tissue parameters as well as degree of cerebral microangiopathy were extracted from the imaging data. Subsequent multivariate Cox regression analysis encompassed TPI, MPD, serum LDH, S100B, age, gender, number of immunotherapy cycles as well as extent of distant metastases. TPI and MPD correlated positively with PFS in multivariate analysis (p = 0.03 and p = 0.001, respectively). Furthermore, single visceral organ and/or soft tissue involvement significantly decreased progression risk (p = 0.01), whereas increased S100B level showed a trend towards PFS shortening (p = 0.05). In conclusion, degree of macroangiopathy and sarcopenia were independent predictors for outcome to immunotherapy and of equivalent significance compared to other clinical biomarkers.
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6
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Pharmacokinetic and cytokine profiles of melanoma patients with dabrafenib and trametinib-induced pyrexia. Cancer Chemother Pharmacol 2019; 83:693-704. [DOI: 10.1007/s00280-019-03780-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/13/2019] [Indexed: 02/07/2023]
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Bucktrout SL, Bluestone JA, Ramsdell F. Recent advances in immunotherapies: from infection and autoimmunity, to cancer, and back again. Genome Med 2018; 10:79. [PMID: 30376867 PMCID: PMC6208073 DOI: 10.1186/s13073-018-0588-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
For at least 300 years the immune system has been targeted to improve human health. Decades of work advancing immunotherapies against infection and autoimmunity paved the way for the current explosion in cancer immunotherapies. Pathways targeted for therapeutic intervention in autoimmune diseases can be modulated in the opposite sense in malignancy and infectious disease. We discuss the basic principles of the immune response, how these are co-opted in chronic infection and malignancy, and how these can be harnessed to treat disease. T cells are at the center of immunotherapy. We consider the complexity of T cell functional subsets, differentiation states, and extrinsic and intrinsic influences in the design, success, and lessons from immunotherapies. The integral role of checkpoints in the immune response is highlighted by the rapid advances in FDA approvals and the use of therapeutics that target the CTLA-4 and PD-1/PD-L1 pathways. We discuss the distinct and overlapping mechanisms of CTLA-4 and PD-1 and how these can be translated to combination immunotherapy treatments. Finally, we discuss how the successes and challenges in cancer immunotherapies, such as the collateral damage of immune-related adverse events following checkpoint inhibition, are informing treatment of autoimmunity, infection, and malignancy.
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Affiliation(s)
- Samantha L Bucktrout
- Parker Institute of Cancer Immunotherapy, 1 Letterman Drive, San Francisco, CA, USA.
| | - Jeffrey A Bluestone
- Parker Institute of Cancer Immunotherapy, 1 Letterman Drive, San Francisco, CA, USA.,Diabetes Center, University of California, San Francisco, San Francisco, CA, 94129, USA
| | - Fred Ramsdell
- Parker Institute of Cancer Immunotherapy, 1 Letterman Drive, San Francisco, CA, USA.
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Zinzani PL, Santoro A, Chiti A, Lastoria S, Pinto A, Rigacci L, Barosi G, Pennisi M, Corradini P. Italian expert panel consensus statement on the optimal use of PD-1 blockade therapy in classical Hodgkin lymphoma. Leuk Lymphoma 2018; 60:1204-1213. [DOI: 10.1080/10428194.2018.1519808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Pier Luigi Zinzani
- Institute of Hematology L. e A. Seràgnoli, University of Bologna, Bologna, Italy
| | - Armando Santoro
- Department of Oncology and Hematology, IRCCS Humanitas Cancer Center, Milan, Italy
| | - Arturo Chiti
- Nuclear Medicine Department, Humanitas Research Hospital and Humanitas University, Milan, Italy
| | - Secondo Lastoria
- Nuclear Medicine Unit, Department of Hematology and Developmental Therapeutics, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy
| | - Antonio Pinto
- Hematology-Oncology and Stem Cell Transplantation Unit, Department of Hematology and Developmental Therapeutics, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy
| | - Lugi Rigacci
- Department of Hematology, University of Florence, Florence, Italy
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Martina Pennisi
- Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, University of Milan, Milan, Italy
| | - Paolo Corradini
- Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, University of Milan, Milan, Italy
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9
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Iskandar A, Hwang A, Dasanu CA. Polymyalgia rheumatica due to pembrolizumab therapy. J Oncol Pharm Pract 2018; 25:1282-1284. [PMID: 30249155 DOI: 10.1177/1078155218800386] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pembrolizumab is a humanized anti-programmed cell death 1 antibody used for the therapy of several malignancies. While autoimmune adverse events are not uncommon with this agent, they are typically mild and self-limiting. Severe autoimmunity is rare but can be life-threatening. Herein, we describe a unique case of severe proximal muscle weakness and joint pain shortly after beginning therapy with pembrolizumab. Work-up revealed elevated pro-inflammatory markers leading to the diagnosis of polymyalgia rheumatica. Steroids allowed for resolution of the joint pain. We call for awareness of this rare autoimmune toxicity with pembrolizumab.
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Affiliation(s)
- Andrew Iskandar
- 1 Department of Medicine, Eisenhower Medical Center, Rancho Mirage, CA, USA
| | - Andrew Hwang
- 1 Department of Medicine, Eisenhower Medical Center, Rancho Mirage, CA, USA
| | - Constantin A Dasanu
- 2 Lucy Curci Cancer Center, Eisenhower Medical Center, Rancho Mirage, CA, USA.,3 UC San Diego Health: Department of Oncology
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Dalakas MC. Neurological complications of immune checkpoint inhibitors: what happens when you 'take the brakes off' the immune system. Ther Adv Neurol Disord 2018; 11:1756286418799864. [PMID: 30245744 PMCID: PMC6144585 DOI: 10.1177/1756286418799864] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 08/18/2018] [Indexed: 12/13/2022] Open
Abstract
Patients with advanced malignancies treated with immune checkpoint inhibitors are at increased risk for developing immune-related neurological complications. It is a phenomenon of immunological twist when immunotherapy against co-stimulatory molecules activates previously normal T cells to kill tumor cells but, in so doing, the T cells become unrestrained, triggering other autoimmune diseases for which conventional immunotherapy is needed. The most common autoimmune neurological diseases, usually occurring within 2-12 weeks after immune checkpoint inhibitor initiation, include: inflammatory myopathies, myasthenia gravis, acute and chronic demyelinating polyradiculoneuropathies, vasculitic neuropathies, isolated cranial neuropathies, aseptic meningitis, autoimmune encephalitis, multiple sclerosis and hypophysitis. The neurological events can evolve rapidly, necessitating the need for vigilance at all stages of treatment, even after completion, because early immunotherapeutic interventions are effective. The review addresses these complications and the applied therapies, discusses immune pathomechanisms including triggering preexisting autoimmunity, highlights the distinction between paraneoplastic and autoimmune etiologies, and identifies uncertainties regarding risk factors, use of immune checkpoint inhibitors in patients with known immune diseases or restarting therapy after a neurological event. Although the autoimmune neurological complications are not very common, their incidence will likely increase as the use of immune checkpoint inhibitors in metastatic cancer is growing rapidly.
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Affiliation(s)
- Marinos C Dalakas
- Chief Neuromuscular Division, Thomas Jefferson University, Philadelphia, PA Chief, Neuroimmunology Unit, Department of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece
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12
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Immune tumor board: integral part in the multidisciplinary management of cancer patients treated with cancer immunotherapy. Virchows Arch 2018; 474:485-495. [PMID: 30143868 DOI: 10.1007/s00428-018-2435-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 12/26/2022]
Abstract
Recent progress in the understanding of immune responses to cancer and how tumor cells evade immune control have led to the successful introduction of cancer immunotherapy, in particular immune checkpoint inhibitors (ICI). Treatment of cancer patients with immunotherapy such as ICIs has led to new challenges, including starting and stopping rules for immunotherapy, the management of immune-related adverse events, and logistic issues for the production of cellular therapies and viral delivery vectors. These challenges are not disease- or organ-specific and several potential biomarkers to predict response to ICI are under investigation. We installed an interdisciplinary discussion platform for managing patient-specific challenges associated with cancer immunotherapy in our institution. Here, we describe an immune tumor board for the management of cancer patients treated with immunotherapy and provide an outlook on how such a platform could be potentially used in the future to discuss rational and personalized combination therapies, and how to improve the management of side effects occurring under immunotherapy.
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Gauci ML, Boudou P, Baroudjian B, Vidal-Trecan T, Da Meda L, Madelaine-Chambrin I, Basset-Seguin N, Bagot M, Pages C, Mourah S, Resche-Rigon M, Pinel S, Sassier M, Rouby F, Eftekhari P, Lebbé C, Gautier JF. Occurrence of type 1 and type 2 diabetes in patients treated with immunotherapy (anti-PD-1 and/or anti-CTLA-4) for metastatic melanoma: a retrospective study. Cancer Immunol Immunother 2018; 67:1197-1208. [PMID: 29808365 PMCID: PMC11028208 DOI: 10.1007/s00262-018-2178-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 05/24/2018] [Indexed: 12/13/2022]
Abstract
Anti-PD-1 and anti-CTLA-4 antibodies cause immune-related side effects such as autoimmune type 1 diabetes (T1D). It has also been suggested that by increasing TNF-α, IL-2 and IFN-γ production, anti-PD-1 and/or anti-CTLA-4 treatment could affect pancreatic beta cell function and insulin sensitivity. This study was based on a retrospective observational analysis from 2 July 2014 to 27 June 2016, which evaluated the occurrence of T1D and changes in glycemia and C-reactive protein (CRP) plasma concentrations in patients undergoing anti-PD-1 and/or anti-CTLA-4 treatment for melanoma at the Saint Louis Hospital. All cases of T1D that developed during immunotherapy registered in the French Pharmacovigilance Database (FPVD) were also considered. Among the 132 patients included, 3 cases of T1D occurred. For the remaining subjects, blood glucose was not significantly affected by anti-PD-1 treatment, but CRP levels (mg/l) significantly increased during anti-PD-1 treatment (p = 0.017). However, 1 case of type 2 diabetes (T2D) occurred (associated with a longer therapy duration). Moreover, glycemia of patients pretreated (n = 44) or concomitantly treated (n = 8) with anti-CTLA-4 tended to increase during anti-PD-1 therapy (p = 0.068). From the FPVD, we obtained 14 cases of T1D that occurred during immunotherapy and were primarily characterized by the rapidity and severity of onset. In conclusion, in addition to inducing this rare immune-related diabetes condition, anti-PD-1 treatment appears to increase CRP levels, a potential inflammatory trigger of insulin resistance, but without any short-term impact on blood glucose level.
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Affiliation(s)
- Marie-Léa Gauci
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France.
| | - Philippe Boudou
- AP-HP Hormonology Department, Saint-Louis Hospital, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Barouyr Baroudjian
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Tiphaine Vidal-Trecan
- AP-HP Diabetology Department, Lariboisière Hospital, INSERM U1138; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Laetitia Da Meda
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Isabelle Madelaine-Chambrin
- AP-HP Pharmacology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Nicole Basset-Seguin
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Martine Bagot
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Cécile Pages
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Samia Mourah
- AP-HP Pharmacogenomic Laboratory, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Matthieu Resche-Rigon
- AP-HP Statistics Department, Saint-Louis Hospital, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Sylvine Pinel
- AP-HP Regional Pharmacologilance Center, Fernand Widal Hospital, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Marion Sassier
- Regional Pharmacovigilance Center of Caen, Caen University Hospital, Caen, France
| | - Franck Rouby
- Department of Clinical Pharmacology, Regional Pharmacovigilance Center of Marseille, Aix-Marseille University, Marseille, France
| | - Pirayeh Eftekhari
- AP-HP Regional Pharmacologilance Center, Fernand Widal Hospital, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Céleste Lebbé
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Jean-François Gautier
- AP-HP Diabetology Department, Lariboisière Hospital, INSERM U1138; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
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Dermatologic Reactions to Immune Checkpoint Inhibitors : Skin Toxicities and Immunotherapy. Am J Clin Dermatol 2018; 19:345-361. [PMID: 29256113 DOI: 10.1007/s40257-017-0336-3] [Citation(s) in RCA: 384] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The development of immune checkpoint inhibitors [monoclonal antibodies targeting cytotoxic T lymphocyte-associated antigen-4 (CTLA-4), programmed cell death protein 1 (PD-1) or programmed death ligand 1 (PD-L1)] represents a major breakthrough in cancer therapy. Although they present a favorable risk/benefit ratio, immune checkpoint blockade therapies have a very specific safety profile. Due to their unique mechanism of action, they entail a new spectrum of adverse events that are mostly immune related [immune-related adverse events (irAEs)], notably mediated by the triggering of cytotoxic CD4+/CD8+ T cell activation. Cutaneous toxicities appear to be one of the most prevalent irAEs, both with anti-PD-1 and anti-CTLA-4 agents or with the newly developed anti-PD-L1 agents, which corresponds to a class effect. They are observed in more than one-third of the treated patients, mainly in the form of a maculopapular rash (eczema-like spongiotic dermatitis) and pruritus. A wide range of other dermatologic manifestations can also occur, including lichenoid reactions, psoriasis, acneiform rashes, vitiligo-like lesions, autoimmune skin diseases (e.g., bullous pemphigoid, dermatomyositis, alopecia areata), sarcoidosis or nail and oral mucosal changes. In addition, the use of anti-CTLA-4 and anti-PD-1 therapies in combination is associated with the development of more frequent, more severe and earlier cutaneous irAEs compared to single agents. In most cases, these dysimmune dermatologic adverse events remain self-limiting and readily manageable. Early recognition and adequate management, however, are critical to prevent exacerbation of the lesions, to limit treatment interruption and to minimize quality of life impairment. This review describes the variable clinical and histopathologic aspects of dermatologic irAEs induced by immune checkpoint inhibitors. Appropriate treatment and counseling are also proposed, with a step-by-step approach for optimized management by both practicing oncologists and dermatologists.
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Kähler KC, Eigentler TK, Gesierich A, Heinzerling L, Loquai C, Meier F, Meiss F, Pföhler C, Schlaak M, Terheyden P, Thoms KM, Ziemer M, Zimmer L, Gutzmer R. Ipilimumab in metastatic melanoma patients with pre-existing autoimmune disorders. Cancer Immunol Immunother 2018; 67:825-834. [PMID: 29487980 PMCID: PMC11028108 DOI: 10.1007/s00262-018-2134-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 02/16/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Ipilimumab and programmed death (PD) 1-antibodies are effective treatment options in metastatic melanoma. The safety and efficacy of ipilimumab in patients with pre-existing autoimmune disorders (AD) has only been evaluated in a selected number of patients. METHODS We performed a retrospective analysis in 14 German skin cancer centers for patients with metastatic melanoma and pre-existing AD treated with ipilimumab. RESULTS 41 patients with 44 pre-existing AD were treated with ipilimumab (thyroiditis n = 15, rheumatoid n = 11, dermatologic n = 10, Crohn's disease/ulcerative colitis n = 3, neurological n = 2, sarcoidosis n = 2, pancreatitis n = 1). 3 out of 41 patients had two AD, 11 patients required immunosuppressants at the time of induction of ipilimumab. 12 patients (29.2%) experienced a flare of their pre-existing AD, mainly patients with rheumatoid or dermatologic diseases. Additional immune-related adverse events (irAEs) occurred in 12 patients (29.2%). In 23 patients (56%) neither a change of their AD nor additional irAEs were observed. Objective responses were seen in five patients (one complete remission, four partial remissions, 12.1%). CONCLUSION This is the largest series of patients with pre-existing AD and treatment with ipilimumab reported. Flares of pre-existing AD were observed but manageable. Response rates and occurrence of new irAEs were comparable to previous trials. Thus, in this patient subgroup, ipilimumab can be a treatment option after a thorough discussion of pros and cons and taking severity and activity of the preexisting AD into account.
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Affiliation(s)
- Katharina C Kähler
- Department of Dermatology, Campus Kiel, University Hospital Schleswig-Holstein (UKSH), Rosalind-Franklind-Str. 7, 24105, Kiel, Germany.
| | - Thomas K Eigentler
- Department of Dermatology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Anja Gesierich
- Department of Dermatology, University Hospital Würzburg, Würzburg, Germany
| | - Lucie Heinzerling
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Carmen Loquai
- Department of Dermatology, University Medical Center of Mainz, Mainz, Germany
| | - Friedegund Meier
- Department of Dermatology, University of Dresden, Dresden, Germany
| | - Frank Meiss
- Department of Dermatology, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Pföhler
- Department of Dermatology, Saarland University Medical School, Homburg/saar, Germany
| | - Max Schlaak
- Department of Dermatology, Skin Cancer Center at Center of Integrated Oncology (CIO), University Hospital Cologne, Cologne-Bonn, Germany
| | - Patrick Terheyden
- Department of Dermatology, Campus LübeckUniversity, Hospital (UKSH), Lübeck, Germany
| | - Kai M Thoms
- Department of Dermatology, University Medical Center Göttingen, Göttingen, Germany
| | - Mirjana Ziemer
- Department of Dermatology, University Hospital Leipzig, Leipzig, Germany
| | - Lisa Zimmer
- Department of Dermatology, Essen, Germany and German Cancer Consortium (DKTK), University Duisburg-Essen, University Hospital Essen, Heidelberg, Germany
| | - Ralf Gutzmer
- Department of Dermatology and Allergy, Skin Cancer Center Hannover, Hannover Medical School, Hanover, Germany
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Postow MA, Sidlow R, Hellmann MD. Immune-Related Adverse Events Associated with Immune Checkpoint Blockade. N Engl J Med 2018; 378:158-168. [PMID: 29320654 DOI: 10.1056/nejmra1703481] [Citation(s) in RCA: 2778] [Impact Index Per Article: 463.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Michael A Postow
- From Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York
| | - Robert Sidlow
- From Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York
| | - Matthew D Hellmann
- From Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York
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Amaral T, Tampouri I, Garbe C. How to use neoadjuvant medical treatment to maximize surgery in melanoma. Expert Rev Anticancer Ther 2018; 18:121-130. [DOI: 10.1080/14737140.2018.1421460] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Teresa Amaral
- Center for Dermatooncology, Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Ioanna Tampouri
- Center for Dermatooncology, Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
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Ascierto PA, Palmieri G, Gogas H. What is changing in the adjuvant treatment of melanoma? Oncotarget 2017; 8:110735-110736. [PMID: 29340009 PMCID: PMC5762277 DOI: 10.18632/oncotarget.22988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 12/03/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Paolo A Ascierto
- Paolo A. Ascierto: Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Napoli, Italy
| | - Giuseppe Palmieri
- Paolo A. Ascierto: Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Napoli, Italy
| | - Helen Gogas
- Paolo A. Ascierto: Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Napoli, Italy
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