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Hong N, Wang B, Zhou HC, Wu ZX, Fang HY, Song GQ, Yu Y. Multidisciplinary management of ulcerative colitis complicated by immune checkpoint inhibitor-associated colitis with life-threatening gastrointestinal hemorrhage: A case report. World J Gastrointest Surg 2024; 16:2329-2336. [DOI: 10.4240/wjgs.v16.i7.2329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 05/26/2024] [Accepted: 06/18/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Programmed cell death 1 (PD-1) inhibitors are immune checkpoint inhibitors (ICI) that have demonstrated significant efficacy in treating various advanced malignant tumors. While most patients tolerate treatment well, several adverse drug reactions, such as fatigue, myelosuppression, and ICI-associated colitis, have been reported.
CASE SUMMARY This case involved a 57-year-old male patient with ulcerative colitis complicated by hepatocarcinoma who underwent treatment with tirelizumab (a PD-1 inhibitor) for six months. The treatment led to repeated life-threatening lower gastrointestinal hemorrhage. The patient received infliximab, vedolizumab, and other salvage procedures but ultimately required subtotal colectomy due to uncontrollable massive lower gastrointestinal bleeding. Currently, postoperative gastrointestinal bleeding has stopped, the patient’s stool has turned yellow, and his full blood cell count has returned to normal.
CONCLUSION This case highlights the necessity of early identification, timely and adequate treatment of ICI-related colitis, and rapid escalation to achieve the goal of improving prognosis.
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Affiliation(s)
- Na Hong
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Bo Wang
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Hang-Cheng Zhou
- Department of Pathology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230036, Anhui Province, China
- Intelligent Pathology Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230036, Anhui Province, China
| | - Zheng-Xiang Wu
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Hua-Ying Fang
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Geng-Qing Song
- Department of Gastroenterology and Hepatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH 44109, United States
| | - Yue Yu
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
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2
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Del Gaudio A, Di Vincenzo F, Petito V, Giustiniani MC, Gasbarrini A, Scaldaferri F, Lopetuso LR. Focus on Immune Checkpoint Inhibitors-related Intestinal Inflammation: From Pathogenesis to Therapeutical Approach. Inflamm Bowel Dis 2024; 30:1018-1031. [PMID: 37801695 PMCID: PMC11144981 DOI: 10.1093/ibd/izad229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Indexed: 10/08/2023]
Abstract
Recently, antitumor immunotherapies have witnessed a breakthrough with the emergence of immune checkpoint inhibitors (ICIs) including programmed cell death-1 (PD-1), programmed cell death-ligand 1 (PD-L1), and cytotoxic T lymphocyte antigen 4 (CTLA-4) inhibitors. Unfortunately, the use of ICIs has also led to the advent of a novel class of adverse events that differ from those of classic chemotherapeutics and are more reminiscent of autoimmune diseases, the immune-related adverse events (IRAEs). Herein, we performed an insight of the main IRAEs associated with ICIs, focusing on gastroenterological IRAEs and specifically on checkpoint inhibitor colitis, which represents the most widely reported IRAE to date. We comprehensively dissected the current evidence regarding pathogenesis, diagnosis, and management of ICIs-induced colitis, touching upon also on innovative therapies.
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Affiliation(s)
- Angelo Del Gaudio
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Federica Di Vincenzo
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Valentina Petito
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | | | - Antonio Gasbarrini
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Franco Scaldaferri
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Loris Riccardo Lopetuso
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- Department of Medicine and Ageing Sciences, G. d’Annunzio University of Chieti-Pescara, Chieti, 66100, Italy
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, Chieti, 66100, Italy
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3
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Kogan L, Townsend MJ, Raj D, Levy AN, Giobbie-Hurder A, Grover S. Prognostic Value of Inflammatory Bowel Disease-associated Biomarkers in Patients With Immune Checkpoint Inhibitor Enterocolitis: A Retrospective Cohort Study. Inflamm Bowel Dis 2024; 30:1032-1035. [PMID: 37421640 DOI: 10.1093/ibd/izad121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Indexed: 07/10/2023]
Abstract
Lay Summary
In the emerging field of immune checkpoint inhibitor enterocolitis, biomarkers to predict disease course are lacking. Select genetic polymorphisms (ATG16L1T300A) and serum amyloid A warrant further study as potential biomarkers associated with severe ICI enterocolitis.
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Affiliation(s)
- Lawrence Kogan
- Division of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | | | - Dhanya Raj
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, MA, USA
| | - Alexander N Levy
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Anita Giobbie-Hurder
- Division of Biostatistics, Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Shilpa Grover
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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4
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Townsend MJ, Benque IJ, Li M, Grover S. Review article: Contemporary management of gastrointestinal, pancreatic and hepatic toxicities of immune checkpoint inhibitors. Aliment Pharmacol Ther 2024; 59:1350-1365. [PMID: 38590108 DOI: 10.1111/apt.17980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/13/2023] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are effective oncologic agents which frequently cause immune-related adverse events (irAEs) which can impact multiple organ systems. Onco-Gastroenterology is a novel and emerging subspecialty within gastroenterology focused on cancer treatment-related complications. Gastroenterologists must be prepared to identify and manage diverse immune-mediated toxicities including enterocolitis, hepatitis, pancreatitis and other ICI-induced toxicities. AIM To provide a narrative review of the epidemiology, diagnostic evaluation and management of checkpoint inhibitor-induced gastrointestinal and hepatic toxicities. METHODS We searched Cochrane and PubMed databases for articles published through August 2023. RESULTS Gastrointestinal and hepatic irAEs include most commonly enterocolitis and hepatitis, but also pancreatitis, oesophagitis, gastritis, motility disorders (gastroparesis) and other rarer toxicities. Guidelines from the National Comprehensive Cancer Network, American Society of Clinical Oncology and European Society for Medical Oncology, in combination with emerging cohort and clinical trial data, offer strategies for management of ICI toxicities. Evaluation of irAEs severity by formal classification and clinical stability, and a thorough workup for alternative etiologies which may clinically mimic irAEs underlie initial management. Treatments include corticosteroids, biologics and other immunosuppressive agents plus supportive care; decisions on dosing, timing and choice of steroid adjuncts and potential for subsequent checkpoint inhibitor dosing are nuanced and toxicity-specific. CONCLUSIONS Expanding clinical trial and cohort data have clarified the epidemiology and clinical characteristics of gastrointestinal, pancreatic and hepatic toxicities of ICIs. Guidelines, though valuable, remain based principally on retrospective cohort data. Quality prospective, controlled studies may refine algorithms for treatment and potential immunotherapy rechallenge.
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Affiliation(s)
- Matthew J Townsend
- Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Isaac J Benque
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Michael Li
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Division of Gastroenterology, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Shilpa Grover
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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5
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Tomm NK, Szczepanski JM, Fang JM, Choi WT, Xue Y, Setia N, Karamchandani DM, Cheng JY, Westerhoff M. Follow-up biopsies in gastrointestinal immune checkpoint inhibitor toxicity may show markedly different inflammatory patterns than initial injury. Hum Pathol 2024; 148:60-65. [PMID: 38734079 DOI: 10.1016/j.humpath.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024]
Abstract
Colitis is a common manifestation of immune checkpoint inhibitor (ICI) toxicity and can present with varied histologic patterns of inflammation, some of which have been shown to be associated with specific ICI drug types. Although the histologic features of ICI colitis seen at the time of diagnosis have been described, there have been few reports following these patients over time. We evaluated initial and follow-up biopsies in 30 patients with ICI colitis and found that 37% of patients developed a different pattern of injury on follow-up biopsy compared to the initial biopsy. Patients with a different inflammatory pattern were more likely to have restarted ICI therapy before their follow-up biopsy (64%) compared to those without a change in inflammatory pattern (11%; P < 0.01). The majority of these patients had changed ICI drug types (86%). Additionally, many cases changed to an inflammatory bowel disease (IBD)-like pattern (36%), raising a question of de novo IBD. However, all of our patients with an IBD-like pattern experienced sustained resolution of symptoms without steroids or other immunosuppressive medications following discontinuation of ICI therapy, consistent with a diagnosis of ICI toxicity. Our findings suggest that follow-up biopsies in patients with ICI colitis may show a different histology and that this does not necessarily warrant a change in the histologic diagnosis to another disease.
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Affiliation(s)
- Nicole K Tomm
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA.
| | - Julianne M Szczepanski
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA
| | - Jiayun M Fang
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA
| | - Won-Tak Choi
- Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, Suite M590, Box 0511, San Francisco, CA, 94143, USA
| | - Yue Xue
- Department of Pathology, Northwestern University Feinberg School of Medicine, 303 E. Chicago Ave., Ward 3-140, Chicago, IL, 60611, USA
| | - Namrata Setia
- Department of Pathology, University of Chicago, 5841 S. Maryland Ave., MC3083 - Rm. S329, Chicago, IL, 60637, USA
| | - Dipti M Karamchandani
- Department of Pathology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Jerome Y Cheng
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA
| | - Maria Westerhoff
- Department of Pathology, University of Michigan, 2800 Plymouth Road, NCRC Bldg 35, Ann Arbor, MI, 48109, USA
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6
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Masheghati F, Asgharzadeh MR, Jafari A, Masoudi N, Maleki-Kakelar H. The role of gut microbiota and probiotics in preventing, treating, and boosting the immune system in colorectal cancer. Life Sci 2024; 344:122529. [PMID: 38490297 DOI: 10.1016/j.lfs.2024.122529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/03/2023] [Accepted: 02/21/2024] [Indexed: 03/17/2024]
Abstract
The gut microbiome plays a significant role in developing colorectal cancer (CRC). The gut microbiome usually acts as a protective barrier against harmful pathogens and infections in the intestine, while also regulating inflammation by affecting the human immune system. The gut microbiota and probiotics play a role not only in intestinal inflammation associated with tumor formation but also in regulating anti-cancer immune response. As a result, they associated with tumor progression and the effectiveness of anti-cancer therapies. Research indicates that gut microbiota and probiotics can be used as biomarkers to predict the impact of immunotherapy and enhance its efficacy in treating CRC by regulating it. This review examines the importance of gut microbiota and probiotics in the development and progression of CRC, as well as their synergistic impact on anti-cancer treatments.
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Affiliation(s)
- Forough Masheghati
- Solid Tumor Research Center, Cellular and Molecular Medicine Research Institute, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Abbas Jafari
- Cellular and Molecular Research Center, Cellular and Molecular Medicine Research Institute, Urmia University of Medical Sciences, Urmia, Iran
| | - Naser Masoudi
- Solid Tumor Research Center, Cellular and Molecular Medicine Research Institute, Urmia University of Medical Sciences, Urmia, Iran; Department of General Surgery, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Hadi Maleki-Kakelar
- Solid Tumor Research Center, Cellular and Molecular Medicine Research Institute, Urmia University of Medical Sciences, Urmia, Iran.
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7
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Yokode M, Shiokawa M, Kawakami H, Kuwada T, Nishikawa Y, Muramoto Y, Kitamoto H, Okabe M, Yamazaki H, Okamoto N, Morita T, Ohno K, Nakanishi R, Takimoto I, Yasuda M, Chikugo K, Matsumoto S, Yoshida H, Ota S, Nakamura T, Okada H, Hirano T, Kakiuchi N, Matsumori T, Yamamoto S, Uza N, Ooi M, Kodama Y, Chiba T, Hayashi H, Seno H. Anti-integrin αvβ6 autoantibodies are a potential biomarker for ulcerative colitis-like immune checkpoint inhibitor-induced colitis. Br J Cancer 2024; 130:1552-1560. [PMID: 38461170 PMCID: PMC11058246 DOI: 10.1038/s41416-024-02647-1] [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: 10/25/2023] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND No specific biomarker for immune checkpoint inhibitor (ICI)-induced colitis has been established. Previously, we identified anti-integrin αvβ6 autoantibodies in >90% of patients with ulcerative colitis (UC). Given that a subset of ICI-induced colitis is similar to UC, we aimed to clarify the relationship between such autoantibodies and ICI-induced colitis. METHODS Serum anti-integrin αvβ6 autoantibody levels were compared between 26 patients with ICI-induced colitis and 157 controls. Endoscopic images of ICI-induced colitis were centrally reviewed. Characteristics of anti-integrin αvβ6 autoantibodies in the ICI-induced colitis patients were compared with those of UC patients. RESULTS Anti-integrin αvβ6 autoantibodies were found in 8/26 (30.8%) patients with ICI-induced colitis and 3/157 (1.9%) controls (P < 0.001). Patients with anti-integrin αvβ6 autoantibodies had significantly more typical UC endoscopic features than those without the autoantibodies (P < 0.001). Anti-integrin αvβ6 autoantibodies in ICI-induced colitis patients were associated with grade ≥3 colitis (P = 0.001) and steroid resistance (P = 0.005). Anti-integrin αvβ6 autoantibody titers correlated with ICI-induced colitis disease activity. Anti-integrin αvβ6 autoantibodies of ICI-induced colitis exhibited similar characteristics to those of UC. CONCLUSIONS Anti-integrin αvβ6 autoantibodies may serve as potential biomarkers for the diagnosis, classification, risk management, and monitoring the disease activity, of ICI-induced colitis.
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Affiliation(s)
- Masataka Yokode
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahiro Shiokawa
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Hisato Kawakami
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka, Japan.
| | - Takeshi Kuwada
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshihiro Nishikawa
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuya Muramoto
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Kitamoto
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Makoto Okabe
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Norihiro Okamoto
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Toshihiro Morita
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Kazuya Ohno
- Department of Gastroenterology, Shizuoka General Hospital, Shizuoka, Japan
| | - Risa Nakanishi
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ikuhisa Takimoto
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Muneji Yasuda
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koki Chikugo
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shimpei Matsumoto
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroyuki Yoshida
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Sakiko Ota
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeharu Nakamura
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirokazu Okada
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomonori Hirano
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobuyuki Kakiuchi
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoaki Matsumori
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuji Yamamoto
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Makoto Ooi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Tsutomu Chiba
- Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Japan
| | - Hidetoshi Hayashi
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Hiroshi Seno
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Adiwinata R, Tandarto K, Tanadi C, Waleleng BJ, Haroen H, Rotty L, Gosal F, Rotty L, Hendratta C, Lasut P, Winarta J, Waleleng A, Simadibrata P, Simadibrata M. Immune Checkpoint Inhibitor Colitis, a Rising Issue in Targeted Cancer Therapy Era: A Literature Review. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2024; 0:rjim-2024-0015. [PMID: 38595047 DOI: 10.2478/rjim-2024-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Indexed: 04/11/2024]
Abstract
Research advances in the oncology treatment field have led to the widespread use of immunotherapy. The usage of immune checkpoint inhibitor (ICI) has improved the survival of cancer patients with metastases. This has also led to the rapidly expanding indications for ICI use. However, ICI usage may lead to toxicity, which may be immune-related, in different organ-specific targets. The immune-related adverse events (irAEs) of ICI may lead to increased morbidity, decreased quality of life, and early termination of ICI. The clinical manifestations of irAEs in the gastrointestinal system are variable, ranging from self-limited to life-threatening or fatal events. In this review article, we would like to focus on discussing ICI-induced colitis, which is one of the most common ICI irAEs in the gastrointestinal tract.
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Affiliation(s)
- Randy Adiwinata
- 1Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
- 2Gastrointestinal Cancer Center, MRCCC Siloam Hospital Semanggi, Jakarta, Indonesia
| | - Kevin Tandarto
- 3Intensive Care Unit, Colombia Asia Hospital, Semarang, Indonesia
| | | | - Bradley Jimmy Waleleng
- 5Division of Gastroenterology-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Harlinda Haroen
- 6Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Linda Rotty
- 6Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Fandy Gosal
- 5Division of Gastroenterology-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Luciana Rotty
- 5Division of Gastroenterology-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Cecilia Hendratta
- 6Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Pearla Lasut
- 6Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Jeanne Winarta
- 5Division of Gastroenterology-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Andrew Waleleng
- 5Division of Gastroenterology-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Sam Ratulangi/Prof. dr. R. D. Kandou Hospital, Manado, Indonesia
| | - Paulus Simadibrata
- 2Gastrointestinal Cancer Center, MRCCC Siloam Hospital Semanggi, Jakarta, Indonesia
- 7Abdi Waluyo Hospital, Jakarta, Indonesia
| | - Marcellus Simadibrata
- 8Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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9
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Pei B, Peng S, Huang C, Zhou F. Bifidobacterium modulation of tumor immunotherapy and its mechanism. Cancer Immunol Immunother 2024; 73:94. [PMID: 38564002 PMCID: PMC10987355 DOI: 10.1007/s00262-024-03665-x] [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: 11/29/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
The advent of tumor immunotherapy in patients has revolutionized the treatment of tumors and significantly improved survival rates for a wide range of tumors. However, the full therapeutic potential of immune checkpoint inhibitors (ICIs) has yet to be realized, as not all patients have a lasting survival benefit from them, and a significant proportion of patients show primary or acquired resistance to immunotherapy. Bifidobacterium is one of the most common probiotics, and its antitumor and immunomodulatory effects have been demonstrated in recent years, but its immunomodulatory effects in tumors, especially on ICIs and in combination, have not been extensively studied in clinical practice, and its effects on the immune system and the mechanisms that modulate immunotherapy are largely unknown. Therefore, this review will focus on the immunomodulatory effects of Bifidobacteria in malignancies and the possible mechanisms of action of Bifidobacteria on immunotherapy in the hope of providing a basis for further research and better application of Bifidobacteria in clinical practice.
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Affiliation(s)
- Bo Pei
- Hubei Key Laboratory of Tumor Biological Behaviors, Department of Radiation Oncology and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Cancer Clinical Study Center, Wuhan, China
- Department of Oncology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, China
| | - Shixuan Peng
- Department of Oncology, Graduate Collaborative Training Base of The First People's Hospital of Xiangtan City, Hengyang Medical School, University of South China, Hengyang, China
| | - Chuying Huang
- Department of Oncology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, China
- Hubei Selenium and Human Health Institute, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
- Hubei Provincial Key Laboratory of Selenium Resources and Bioapplications, Enshi, China
| | - Fuxiang Zhou
- Hubei Key Laboratory of Tumor Biological Behaviors, Department of Radiation Oncology and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Cancer Clinical Study Center, Wuhan, China.
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10
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Jeay M, Carbonnel F, Robert C, Mussini C, Bellanger C, Meyer A. Chronic gastrointestinal immune-related adverse events in patients exposed to immune checkpoint inhibitors. Clin Res Hepatol Gastroenterol 2024; 48:102311. [PMID: 38430989 DOI: 10.1016/j.clinre.2024.102311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/13/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND AND AIMS Immune checkpoint inhibitors (ICI) cause acute gastrointestinal (GI) immune-related adverse events (IrAEs). We aimed to report and describe chronic GI IrAEs. METHODS We included consecutive patients addressed to a single center between October 2010 and March 2022 for endoscopic and/or histological GI inflammation persisting at least six months after the last dose of ICI. RESULTS Among a total of 178 patients addressed for GI IrAE, 14 met the inclusion criteria (8 %). The median follow-up was 13 months after discontinuation of ICI. The most common symptom was watery diarrhea (54 %). Ten (77 %) patients had colonic involvement and three patients (21 %) had ileal involvement. Ten patients (77 %) had inflammatory lesions, two patients (15 %) had fistulas and one patient had (8 %) a stricture. All patients had lymphoplasmacytic infiltrate and basal plasmacytosis, and seven (54 %) had crypt distortions. Nine patients (69 %) received medical therapy, including five patients treated with vedolizumab, two patients (15 %) underwent intestinal resection. At the last follow-up, seven of the 13 patients were receiving maintenance therapy. Endoscopic lesions persisted one year after discontinuing ICI in 4/6 patients, and two years after discontinuation in 3/4 patients. CONCLUSIONS Chronic GI IrAEs exist after ICI use.
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Affiliation(s)
- Marine Jeay
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin Bicêtre, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Franck Carbonnel
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin Bicêtre, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Caroline Robert
- Dermatology Unit, Department of Medicine, Gustave Roussy, Villejuif, France & Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Charlotte Mussini
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin Bicêtre, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Christophe Bellanger
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin Bicêtre, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Antoine Meyer
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin Bicêtre, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France.
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11
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Riveiro-Barciela M, Carballal S, Díaz-González Á, Mañosa M, Gallego-Plazas J, Cubiella J, Jiménez-Fonseca P, Varela M, Menchén L, Sangro B, Fernández-Montes A, Mesonero F, Rodríguez-Gandía MÁ, Rivera F, Londoño MC. Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:401-432. [PMID: 38228461 DOI: 10.1016/j.gastrohep.2023.10.009] [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: 06/12/2023] [Revised: 09/28/2023] [Accepted: 10/19/2023] [Indexed: 01/18/2024]
Abstract
The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2% to 40%, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona (UAB), Department of Medicine, Spain.
| | - Sabela Carballal
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Universitat de Barcelona, Spain
| | - Álvaro Díaz-González
- Gastroenterology Department, Grupo de Investigación Clínica y Traslacional en Enfermedades Digestivas, Instituto de Investigación Valdecilla (IDIVAL), Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Míriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Joaquín Cubiella
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Universitario de Ourense, Grupo de Investigación en Oncología Digestiva-Ourense, Spain
| | - Paula Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - María Varela
- Gastroenterology Department, Hospital Universitario Central de Asturias, IUOPA, ISPA, FINBA, University of Oviedo, Oviedo, Spain
| | - Luis Menchén
- Servicio de Aparato Digestivo - CEIMI, Instituto de Investigación Sanitaria Gregorio, Marañón, Spain; Departamento de Medicina, Universidad Complutense, Madrid, Spain
| | - Bruno Sangro
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Cancer Center Clinica Universidad de Navarra, Pamplona-Madrid, Spain
| | - Ana Fernández-Montes
- Medical Oncology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Francisco Mesonero
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Universidad de Alcalá de Henares, Spain
| | - Miguel Ángel Rodríguez-Gandía
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRyCIS), Madrid, Spain
| | - Fernando Rivera
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - María-Carlota Londoño
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat de Barcelona, Spain; Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Spain
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12
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Lei C, Kong X, Li Y, Yang H, Zhang K, Wang Z, Chang H, Xuan L. PD-1/PD-L1 Inhibitor - Related Adverse Events and Their Management in Breast Cancer. J Cancer 2024; 15:2770-2787. [PMID: 38577606 PMCID: PMC10988294 DOI: 10.7150/jca.85433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 03/03/2024] [Indexed: 04/06/2024] Open
Abstract
As the positive results of multiple clinical trials were released, the Programmed cell death 1 (PD-1) and Programmed cell death ligand 1 (PD-L1) inhibitors emerge as the focus of integrative breast cancer treatment. PD-1/PD-L1 inhibitors are often used as a sequential agent to be combined with other agents such as chemotherapeutic agents, targeted agents, and radiation therapy. As multiple therapies are administered simultaneously or in sequence, they are prone to a variety of adverse effects on patients while achieving efficacy. It is a challenge for clinicians to maintaining the balance between immune-related adverse effects(irAEs) and treatment efficacy. Previous literatures have paid lots of attention on the adverse effects caused by immunosuppressive agents themselves, while there is a dearth of the research on the management of adverse immune effects during the combination of immunotherapy with other treatments. In this review, we discuss the overall incidence of irAEs caused by PD-1/PD-L1 inhibitors in combination with various types of treatments in breast cancer, including chemotherapy, CTLA-4 inhibitors, targeted therapy, and radiotherapy, and systematically summarizes the clinical management to each organ-related adverse immune reaction. It is important to emphasize that in the event of irAEs such as neurological, hematologic, and cardiac toxicity, there is no alternative treatment but to terminate immunotherapy. Thus, seeking more effective strategy of irAEs' management is imminent and clinicians are urged to raise the awareness of the management of adverse immune reactions.
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Affiliation(s)
- Chuqi Lei
- 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
| | - 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
| | - Yuan Li
- 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
| | - Huaiyu Yang
- 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
| | - Ke Zhang
- 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
| | - Zhongzhao 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
| | - Hu Chang
- Administration Office, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Lixue Xuan
- 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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13
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Velikova T, Krastev B, Gulinac M, Zashev M, Graklanov V, Peruhova M. New strategies in the diagnosis and treatment of immune-checkpoint inhibitor-mediated colitis. World J Clin Cases 2024; 12:1050-1062. [PMID: 38464930 PMCID: PMC10921308 DOI: 10.12998/wjcc.v12.i6.1050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 02/20/2024] Open
Abstract
Immune-checkpoint inhibitor-mediated colitis (IMC) is an increasingly recognized adverse event in cancer immunotherapy, particularly associated with immune checkpoint inhibitors (ICIs) such as anti-cytotoxic T-lymphocyte antigen-4 and anti-programmed cell death protein-1 antibodies. As this revolutionary immunotherapy gains prominence in cancer treatment, understanding, diagnosing, and effectively managing IMC becomes paramount. IMC represents a unique challenge due to its immune-mediated nature and potential for severe complications. However, a precise picture of IMC pathophysiology is currently unavailable. Therefore, we aimed to summarize the existing data while acknowledging the need for further research. This comprehensive review explores the mechanisms underlying ICIs, gastrointestinal adverse effects, and, in particular, IMC's incidence, prevalence, and features. Our review also emphasizes the importance of recognizing IMC's distinct clinical and histopathological features to differentiate it from other forms of colitis. Furthermore, this paper highlights the urgent need for evolving diagnostic methods, therapeutic strategies, and a multidisciplinary approach to effectively manage IMC.
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Affiliation(s)
- Tsvetelina Velikova
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
| | - Boris Krastev
- Medical Center Nadezhda, Medical Center Nadezhda, Sofia 1407, Bulgaria
| | - Milena Gulinac
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
- General and Clinical Pathology, Medical University of Plovdiv, Plovdiv 4002, Bulgaria
| | - Miroslav Zashev
- Department of General Surgery, University Hospital “Heart and Brain”, Burgas 8000, Bulgaria
| | - Vasko Graklanov
- First Department of Internal Diseases, Medical University of Plovdiv, Plovdiv 4000, Bulgaria
- Department of Hematology, University Hospital “St. George”, Plovdiv 4000, Bulgaria
| | - Milena Peruhova
- Division of Gastroenterology, University Hospital “Heart and Brain”, Burgas 1000, Bulgaria
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14
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Riveiro-Barciela M, Carballal S, Díaz-González Á, Mañosa M, Gallgo-Plazas J, Cubiella J, Jiménez-Fonseca P, Varela M, Menchén L, Sangro B, Fernández-Montes A, Mesonero F, Rodríguez-Gandía MÁ, Rivera F, Londoño MC. Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:83-113. [PMID: 38226597 DOI: 10.17235/reed.2024.10250/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2 % to 40 %, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events.
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Affiliation(s)
| | | | | | - Miriam Mañosa
- Gastroenterology, Hospital Universitari Germans Trias i Pujol
| | | | | | | | - María Varela
- Gastroenterology, Hospital Universitario Central de Asturias
| | - Luis Menchén
- Digestive Diseases, Instituto de Investigación Sanitaria Gregorio Marañón
| | | | | | | | | | - Fernando Rivera
- Hospital Universitario Marqués de Valdecilla, Medical Oncology
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15
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Lei H, Sun W, Liu X, Wang C. Clinical characteristics, diagnosis, treatment, and prognosis of nivolumab induced gastritis. Invest New Drugs 2024; 42:53-59. [PMID: 38063991 DOI: 10.1007/s10637-023-01412-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 02/24/2024]
Abstract
Gastritis has recently been reported to be associated with nivolumab, and the clinical characteristics of nivolumab induced gastritis remain unclear. To explore the clinical characteristics of nivolumab induced gastritis, and to provide reference for the classification and treatment guidelines of immune checkpoint inhibitors -related gastritis. Case reports, case series, and clinical studies of nivolumab induced gastritis were retrospectively analyzed by searching the database from the establishment of the database until September 30, 2023. Forty-seven were included, with a median age of 57 years (range 16, 93). The median time of symptom onset was 6 months (range 0.5,36) and 6.5 cycles (range 2, 62). Nausea (29 cases, 61.7%), vomiting (29 cases, 61.7%), and epigastric pain (28 cases, 59.6%) were the most common complaints. Esophagogastroduodenoscopy mainly showed erythema (28 cases, 59.6%). Gastric mucosa biopsy showed epithelial inflammatory cell infiltration (22 cases, 46.8%) and apoptosis (15 cases, 31.9%). Most patients' symptoms and gastric mucosa improved or recovered after receiving systemic steroid and proton pump inhibitor therapy regardless of whether nivolumab was discontinued. Two patients died from gastritis related events. Gastritis should be considered as the cause of unexplained epigastric symptoms in the administration of nivolumab. Understanding the clinical features of nivolumab induced gastritis is very important for accurate diagnosis and timely management of these patients.
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Affiliation(s)
- Haibo Lei
- Department of Clinical Pharmacy, Xiangtan Central Hospital, No. 120 Heping Road, Yuhu District, Xiangtan, 411100, Hunan, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, Changsha, 410013, China
| | - Xiang Liu
- Department of Clinical Pharmacy, Xiangtan Central Hospital, No. 120 Heping Road, Yuhu District, Xiangtan, 411100, Hunan, China.
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, Changsha, 410013, China.
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16
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Harvey C, Nahar KJ, McKeown J, Lo SN, Farag S, Yousaf N, Young K, Tas L, Meerveld-Eggink A, Blank C, Thomas A, McQuade J, Schilling B, Johnson DB, Huertas RM, Arance A, Lee J, Zimmer L, Long GV, Carlino MS, Wang Y, Menzies AM. Management of infliximab refractory immune checkpoint inhibitor gastrointestinal toxicity: a multicenter case series. J Immunother Cancer 2024; 12:e008232. [PMID: 38296594 PMCID: PMC10831444 DOI: 10.1136/jitc-2023-008232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) gastrointestinal toxicity (gastritis, enteritis, colitis) is a major cause of morbidity and treatment-related death. Guidelines agree steroid-refractory cases warrant infliximab, however best management of infliximab-refractory ICI gastrointestinal toxicity (IRIGItox) is unknown. METHODS We conducted an international multicenter retrospective case series. IRIGItox was defined as failure of symptom resolution ≤grade 1 (Common Terminology Criteria for Adverse Events V.5.0) following ≥2 infliximab doses or failure of symptom resolution ≤grade 2 after one dose. Data were extracted regarding demographics, steroid use, response to treatment, and survival outcomes. Toxicity was graded at symptom onset and time of infliximab failure. Efficacy of infliximab refractory therapy was assessed by symptom resolution, time to resolution and steroid wean duration. Survival outcomes were examined based on immunosuppressive therapy received. RESULTS 78 patients were identified: median age 60 years; 56% men; majority melanoma (N=70, 90%); 60 (77%) received anti-cytotoxic T-lymphocyte-associated protein 4 alone or in combination with anti-programmed cell death protein-1 and most had colitis (N=74, 95%). 106 post-infliximab treatments were given: 31 calcineurin inhibitors (CNIs); 27 antimetabolites (mycophenolate, azathioprine); 16 non-systemic immunomodulatory agents (eg, mesalazine or budesonide); 15 vedolizumab; 5 other biologics (anti-interleukin-12/23, 16, Janus kinase inhibitors) and 7 interventional procedures (including colectomy); 5 did not receive post-infliximab therapy. Symptom resolution was achieved in most (N=23/31, 74%) patients treated with CNIs; 12/27 (44%) with antimetabolites; 7/16 (44%) with non-systemic immunomodulation, 8/15 (53%) with vedolizumab and 5/7 (71%) with interventional procedures. No non-vedolizumab biologics resulted in toxicity resolution. CNIs had the shortest time to symptom resolution (12 days) and steroid wean (43 days); however, were associated with poorer event-free survival (6.3 months) and overall survival (26.8 months) than other agents. Conversely, vedolizumab had the longest time to toxicity resolution and steroid wean, 66 and 124 days, but most favorable survival data: EFS 24.5 months; median OS not reached. Six death occurred (three due to IRIGItox or management of toxicity; three with persisting IRIGItox and progressive disease). CONCLUSIONS IRIGItox causes major morbidity and mortality. Management is heterogeneous. CNIs appear most likely to result in toxicity resolution in the shortest time period, however, are associated with poorer oncological outcomes in contrast to vedolizumab.
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Affiliation(s)
- Catriona Harvey
- Westmead Hospital WNH, Westmead, New South Wales, Australia
- Melanoma Institute Australia, North Sydney, New South Wales, Australia
| | - Kazi J Nahar
- Melanoma Institute Australia, North Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Janet McKeown
- Melanoma Institute Australia, North Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Serigne N Lo
- Research and Biostatistics Group, Melanoma Institute Australia, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | | | - Kate Young
- Royal Marsden Hospital NHS Trust, London, UK
| | - Liselotte Tas
- Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | - Austin Thomas
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jennifer McQuade
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | | | - Ana Arance
- Hospital Clinic and Institut D'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Joanna Lee
- The University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Lisa Zimmer
- Dermatology, University Hospital Essen, Essen, Germany
| | - Georgina V Long
- Melanoma Institute Australia, Wollstonecraft, New South Wales, Australia
| | | | - Yinghong Wang
- Gastroenterology, Hepatology & Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexander Maxwell Menzies
- Melanoma Institute Australia, North Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
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Dougan M, Nguyen LH, Buchbinder EI, Lazarus HM. Sargramostim for Prophylactic Management of Gastrointestinal Immune-Related Adverse Events of Immune Checkpoint Inhibitor Therapy for Cancer. Cancers (Basel) 2024; 16:501. [PMID: 38339253 PMCID: PMC10854719 DOI: 10.3390/cancers16030501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Immune checkpoint inhibitor (ICI) therapy improves outcomes in several cancers. Unfortunately, many patients experience grade 3-4 treatment-related adverse events, including gastrointestinal (GI) toxicities which are common. These GI immune-related adverse events (irAEs) induced by ICIs present significant clinical challenges, require prompt intervention, and result in treatment delays or discontinuations. The treatment for these potentially severe and even fatal GI irAEs which include enterocolitis, severe diarrhea, and hepatitis may interfere with the anti-cancer approach. Sargramostim (glycosylated, yeast-derived, recombinant human GM-CSF) is an agent that has been used in clinical practice for more than 30 years with a well-recognized safety profile and has been studied in many therapeutic areas. The mechanism of action of sargramostim may treat moderate-to-severe GI irAEs without impairing the anti-cancer therapy. Some early data also suggest a potential survival benefit. Through the differentiation/maturation of monocytes, macrophages, and neutrophils and induction of anti-inflammatory T cell responses, GM-CSF aids in GI homeostasis, mucosal healing, and mucosal immunity. GM-CSF knockout mice are susceptible to severe colitis which was prevented with murine GM-CSF administration. For some patients with GI mucosa and immune cell function impairment, e.g., Crohn's disease, sargramostim reduces disease severity. In a prospective, randomized study (ECOG 1608), advanced melanoma patients had a reduction in grade 3-5 GI irAEs and less frequent colonic perforation in the sargramostim plus ipilimumab arm compared to ipilimumab alone. Sargramostim continues to be studied with ICIs for the prophylactic management of irAEs while also potentially providing a survival benefit.
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Affiliation(s)
- Michael Dougan
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA; (M.D.); (E.I.B.)
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Long H. Nguyen
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA;
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Elizabeth I. Buchbinder
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA; (M.D.); (E.I.B.)
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Hillard M. Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH 44106, USA
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Daetwyler E, Wallrabenstein T, König D, Cappelli LC, Naidoo J, Zippelius A, Läubli H. Corticosteroid-resistant immune-related adverse events: a systematic review. J Immunother Cancer 2024; 12:e007409. [PMID: 38233099 PMCID: PMC10806650 DOI: 10.1136/jitc-2023-007409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 01/19/2024] Open
Abstract
Immune checkpoint inhibitor (ICI) treatment has become an important therapeutic option for various cancer types. Although the treatment is effective, ICI can overstimulate the patient's immune system, leading to potentially severe immune-related adverse events (irAEs), including hepatitis, colitis, pneumonitis and myocarditis. The initial mainstay of treatments includes the administration of corticosteroids. There is little evidence how to treat steroid-resistant (sr) irAEs. It is mainly based on small case series or single case reports. This systematic review summarizes available evidence about sr-irAEs. We conducted a systematic literature search in PubMed. Additionally, we included European Society for Medical Oncology, Society for Immunotherapy of Cancer, National Comprehensive Cancer Network and American Society of Clinical Oncology Guidelines for irAEs in our assessment. The study population of all selected publications had to include patients with cancer who developed hepatitis, colitis, pneumonitis or myocarditis during or after an immunotherapy treatment and for whom corticosteroid therapy was not sufficient. Our literature search was not restricted to any specific cancer diagnosis. Case reports were also included. There is limited data regarding life-threatening sr-irAEs of colon/liver/lung/heart and the majority of publications are single case reports. Most publications investigated sr colitis (n=26), followed by hepatitis (n=21), pneumonitis (n=17) and myocarditis (n=15). There is most data for mycophenolate mofetil (MMF) to treat sr hepatitis and for infliximab, followed by vedolizumab, to treat sr colitis. Regarding sr pneumonitis there is most data for MMF and intravenous immunoglobulins (IVIG) while data regarding infliximab are conflicting. In sr myocarditis, most evidence is available for the use of abatacept or anti-thymocyte globulin (ATG) (both with or without MMF) or ruxolitinib with abatacept. This review highlights the need for prompt recognition and treatment of sr hepatitis, colitis, pneumonitis and myocarditis. Guideline recommendations for sr situations are not defined precisely. Based on our search, we recommend-as first line treatment-(1) MMF for sr hepatitis, (2) infliximab for sr colitis, followed by vedolizumab, (3) MMF and IVIG for sr pneumonitis and (4) abatacept or ATG (both with or without MMF) or ruxolitinib with abatacept for sr myocarditis. These additional immunosuppressive agents should be initiated promptly if there is no sufficient response to corticosteroids within 3 days.
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Affiliation(s)
- Eveline Daetwyler
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Till Wallrabenstein
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Division of Hematology and Medical Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - David König
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Laura C Cappelli
- Divison of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Alfred Zippelius
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Heinz Läubli
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
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Kazim M, Yoo E. Recent Advances in the Development of Non-Invasive Imaging Probes for Cancer Immunotherapy. Angew Chem Int Ed Engl 2024; 63:e202310694. [PMID: 37843426 DOI: 10.1002/anie.202310694] [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: 07/26/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/17/2023]
Abstract
The last two decades have witnessed a major revolution in the field of tumor immunology including clinical progress using various immunotherapy strategies. These advances have highlighted the potential for approaches that harness the power of the immune system to fight against cancer. While cancer immunotherapies have shown significant clinical successes, patient responses vary widely due to the complex and heterogeneous nature of tumors and immune responses, calling for reliable biomarkers and therapeutic strategies to maximize the benefits of immunotherapy. Especially, stratifying responding individuals from non-responders during the early stages of treatment could help avoid long-term damage and tailor personalized treatments. In efforts to develop non-invasive means for accurately evaluating and predicting tumor response to immunotherapy, multiple affinity-based agents targeting immune cell markers and checkpoint molecules have been developed and advanced to clinical trials. In addition, researchers have recently turned their attention to substrate and activity-based imaging probes that can provide real-time, functional assessment of immune response to treatment. Here, we highlight some of those recently designed probes that image functional proteases as biomarkers of cancer immunotherapy with a focus on their chemical design and detection modalities and discuss challenges and opportunities for the development of imaging tools utilized in cancer immunotherapy.
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Affiliation(s)
- Muhammad Kazim
- Chemical Biology Laboratory, National Cancer Institute, National Institutes of Health, Frederick, MD 21702, USA
| | - Euna Yoo
- Chemical Biology Laboratory, National Cancer Institute, National Institutes of Health, Frederick, MD 21702, USA
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20
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Gómez Escudero O. Enterocolitis and other immunotherapy and targeted therapy-related gastrointestinal manifestations: A review for gastroenterologist. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:89-105. [PMID: 38485558 DOI: 10.1016/j.rgmxen.2023.11.001] [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: 07/21/2023] [Accepted: 11/08/2023] [Indexed: 04/20/2024]
Abstract
New oncologic treatments, particularly immunotherapy (IT), have revolutionized the treatment of advanced-stage malignant tumors. Immune checkpoint inhibitors are the main form of IT and act by increasing T cell activity and the organism's immune response against neoplastic cells. Targeted therapy is another form of IT that acts by inhibiting oncogenes or inflammation signaling and tumor angiogenesis pathways. However, these mechanisms of tumor destruction can interfere with the host's immune self-tolerance or with the mechanisms of epithelial tissue repair and predispose to immune system-mediated adverse events that can affect multiple organs, including the digestive tract. The gastrointestinal manifestations of damage caused by IT can range from low-grade mucositis to ulceration, and in some cases, necrosis and perforation. Any part of the gastrointestinal tract can be affected, but there is greater involvement of the small bowel and colon, with a pattern similar to that seen in inflammatory bowel disease. The most common clinical manifestation is chronic diarrhea. The differential diagnosis includes enteropathogenic infections, especially those caused by opportunistic microorganisms; adverse drug reactions; and other inflammatory and malabsorption disorders. Treatment is guided by damage severity. Mild cases can be treated with antidiarrheals and rehydration in the outpatient setting; moderate cases with hospitalization, systemic steroids, and temporary suspension of IT; and severe cases with immunosuppressants or biologic agents and definitive suspension of IT.
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Affiliation(s)
- O Gómez Escudero
- Clínica de Gastroenterología, Endoscopia Digestiva y Motilidad Gastrointestinal «Endoneurogastro», Hospital Ángeles, Puebla, Mexico.
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21
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Enwerem NY, Yen EF. The colitis may be microscopic, but the diarrhea is not: update on the treatment of microscopic colitis and immune checkpoint inhibitor colitis. Curr Opin Gastroenterol 2024; 40:50-59. [PMID: 37874119 DOI: 10.1097/mog.0000000000000986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW Microscopic colitis is an inflammatory disease of the colon that presents as watery diarrhea with minimal to normal endoscopic changes on colonoscopy. It encompasses two common subtypes, lymphocytic colitis and collagenous colitis, which are both treated similarly.Immune checkpoint inhibitor colitis is among the most common immune-related adverse events. Endoscopic and histological findings range from normal colonic mucosa to inflammatory bowel like changes. This review article provides update in treatment and management of microscopic colitis and immune checkpoint inhibitor colitis (ICPi colitis). RECENT FINDINGS Recent studies on microscopic colitis have focused on the successful use of immunomodulators such as biologics for treatment of budesonide refractory microscopic colitis cases. Microscopic colitis does not confer an added risk for colorectal cancer.With the increasing usage of immunotherapy agents, immune checkpoint inhibitor colitis is becoming more common. ICPi colitis can be successfully managed with steroids, with treatment stepped up to biologics for moderate to severe cases or for mild cases that do not respond to steroids. Immunotherapy agents can be carefully re-introduced in mild cases, after treatment of ICPi colitis. SUMMARY Biologics can be used to treat budesonide refractory microscopic colitis. ICPi colitis can be managed with steroids and biologics in moderate to severe cases.
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Affiliation(s)
- Ngozi Y Enwerem
- University of Texas Southwestern Medical Center, Division of Digestive and Liver Diseases
- VA Medical Center, Dallas, Texas
| | - Eugene F Yen
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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22
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Mitchell JM, Karamchandani DM. Histopathologic Manifestations of Immune Checkpoint Inhibitor Therapy-Associated Gastrointestinal Tract Injury: A Practical Review. Surg Pathol Clin 2023; 16:703-718. [PMID: 37863561 DOI: 10.1016/j.path.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Immune checkpoint inhibitors have revolutionized the management of many advanced cancers by producing robust remissions. They mostly target two immune regulatory pathways: cytotoxic T lymphocyte antigen-4 and programmed death-1 or its ligand. However, a flip side is the immune-related adverse events (irAEs) commonly affecting the gastrointestinal (GI) tract that can cause treatment interruptions or discontinuation. This practical review discusses the clinical and histopathologic findings of irAEs encountered in the luminal GI tract, along with histopathologic differentials that can mimic varied inflammatory, infectious, or other medication-associated etiologies and the importance of clinico-pathologic correlation for an accurate diagnosis.
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Affiliation(s)
- James Michael Mitchell
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA. https://twitter.com/GIJamesMD
| | - Dipti M Karamchandani
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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23
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Bresteau C, Bonnet P, Robert C, Mussini C, Saiag P, Buecher B, Lebbe C, Allez M, Benamouzig R, Hagège H, Bécheur H, Meyer A, Carbonnel F. Serious immune-related upper gastrointestinal toxicity of immune checkpoint inhibitors: a multicenter case series. J Gastroenterol Hepatol 2023; 38:2104-2110. [PMID: 37710354 DOI: 10.1111/jgh.16349] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/17/2023] [Accepted: 08/26/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) improve the prognosis of many cancers but cause immune-related adverse events (IrAEs). Limited data are available on upper gastrointestinal (UGI) IrAEs. We describe the clinical characteristics, prognosis, and efficacy of medical therapy in patients with UGI IrAEs. METHODS This is a retrospective, multicenter cohort study of patients with UGI symptoms and moderate to severe endoscopic UGI lesions, occurring after ICI. Efficacy of induction medical therapy and at the most recent follow-up was assessed. RESULTS Forty patients were included; of these, 34 (85%) received anti-PD(L)1, either alone (n = 24) or combined with anti CTLA-4 (n = 10). Eighteen patients (45%) had concomitant enterocolitis. All patients had severe endoscopic lesions (erosions, ulcerations, hemorrhage, or necrotic lesions). Three patients who received an inefficient initial medical treatment had a complicated course: One patient died of enterocolitis, one had a pneumomediastinum, and one developed an ulcerated stricture of the pylorus. Thirty-five patients (88%) were treated with corticosteroids; 28 patients (80%) responded, and 20 (57%) reached clinical remission. Eight patients were treated with infliximab, and six responded (75%). After a median follow-up of 11 months, 36 patients (90%) were in corticosteroid-free clinical remission for their UGI symptoms. Endoscopic lesions persisted in 68% of patients. CONCLUSIONS ICI cause severe UGI IrAEs, which are associated with enterocolitis in approximately half of the patients. Most patients with UGI IrAEs respond to corticosteroids or infliximab. These data support the recommendation to treat these patients without delay and in the same way as those with enterocolitis.
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Affiliation(s)
- Clément Bresteau
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin Bicêtre, France
- Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Pauline Bonnet
- Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Université Versailles Saint-Quentin-en-Yvelines, Boulogne-Billancourt, France
| | - Caroline Robert
- Université Paris-Saclay, Le Kremlin Bicêtre, France
- Institut Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Charlotte Mussini
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Philippe Saiag
- Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Université Versailles Saint-Quentin-en-Yvelines, Boulogne-Billancourt, France
| | - Bruno Buecher
- Institut Curie, PSL Research University, Départements de Génétique et d'Oncologie Médicale, Paris, France
| | - Celeste Lebbe
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint Louis, Université Paris Cité, Dermato-Oncology; INSERM U976, Paris, France
| | - Matthieu Allez
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Robert Benamouzig
- Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Université Sorbonne Paris Nord, Bobigny, France
| | - Hervé Hagège
- Hôpital Intercommunal de Créteil, Hépato-Gastro-Entérologie, Créteil, France
| | - Hakim Bécheur
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Université Paris Cité, Paris, France
| | - Antoine Meyer
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin Bicêtre, France
- Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Franck Carbonnel
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin Bicêtre, France
- Université Paris-Saclay, Le Kremlin Bicêtre, France
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24
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Araki T, Kanda S, Ide T, Sonehara K, Komatsu M, Tateishi K, Minagawa T, Kiniwa Y, Kawakami S, Nomura S, Okuyama R, Hanaoka M, Koizumi T. Antiplatelet drugs may increase the risk for checkpoint inhibitor-related pneumonitis in advanced cancer patients. ESMO Open 2023; 8:102030. [PMID: 37852033 PMCID: PMC10774871 DOI: 10.1016/j.esmoop.2023.102030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/31/2023] [Accepted: 09/20/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are indicated for various cancers and are the mainstay of cancer immunotherapy. They are often associated with ICI-related pneumonitis (CIP), however, hindering a favorable clinical course. Recently, non-oncology concomitant drugs have been reported to affect the efficacy and toxicity of ICIs; however, the association between these drugs and the risk for CIP is uncertain. The aim of this study was to assess the impact of baseline concomitant drugs on CIP incidence in ICI-treated advanced cancer patients. PATIENTS AND METHODS This was a single-center retrospective study that included a cohort of 511 patients with advanced cancer (melanoma and non-small-cell lung, head and neck, genitourinary, and other types of cancer) treated with ICIs. Univariable analysis was conducted to identify baseline co-medications associated with CIP incidence. A propensity score matching analysis was used to adjust for potential CIP risk factors, and multivariable analysis was carried out to assess the impact of the identified co-medications on CIP risk. RESULTS Forty-seven (9.2%) patients developed CIP. In these patients, the organizing pneumonia pattern was the dominant radiological phenotype, and 42.6% had grade ≥3 CIP, including one patient with grade 5. Of the investigated baseline co-medications, the proportion of antiplatelet drugs (n = 50, 9.8%) was higher in patients with CIP (23.4% versus 8.4%). After propensity score matching, the CIP incidence was higher in patients with baseline antiplatelet drugs (22% versus 6%). Finally, baseline antiplatelet drug use was demonstrated to increase the risk for CIP incidence regardless of cancer type (hazard ratio, 3.46; 95% confidence interval 1.21-9.86). CONCLUSIONS An association between concomitant antiplatelet drug use at baseline and an increased risk for CIP was seen in our database. This implies the importance of assessing concomitant medications for CIP risk management.
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Affiliation(s)
- T Araki
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - S Kanda
- Department of Hematology and Medical Oncology, Shinshu University School of Medicine, Matsumoto, Japan.
| | - T Ide
- Department of Pharmacy, Shinshu University School of Medicine, Matsumoto, Japan
| | - K Sonehara
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - M Komatsu
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - K Tateishi
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - T Minagawa
- Department of Urology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Y Kiniwa
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - S Kawakami
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - S Nomura
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - R Okuyama
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - M Hanaoka
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - T Koizumi
- Department of Hematology and Medical Oncology, Shinshu University School of Medicine, Matsumoto, Japan
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25
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Nijhawan HP, Prabhakar B, Misra A, Yadav KS. Fragmented antibodies in non-small cell lung cancer: A novel nano-engineered delivery system for detection and treatment of cancer. Drug Discov Today 2023; 28:103701. [PMID: 37453459 DOI: 10.1016/j.drudis.2023.103701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 05/08/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
Non-small cell lung cancer (NSCLC) has a long history of defying traditional cytotoxic treatment. Significant advancements in biotechnology, cancer biology, and immunotherapy have provided new insights that have altered the landscape for the management of NSCLC, clearing the way for a new era of pharmaceuticals in the form of monoclonal antibodies and their fragments. Antibody fragments are superior to monoclonal antibodies because of their small size, which allows them to penetrate cells and tissues effectively. When combined with functional nanocarriers, antibody fragments can target cancer cells while offering improved efficacy and fewer off-target effects. We discuss current topics of interest including anti-CTLA-4 mAbs, Talactoferrin alfa (TLF), and the CYFRA 21-1 biomarker, with brief insights into its novel detection system.
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Affiliation(s)
- Harsh P Nijhawan
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS Deemed to be University, Vile-Parle (W), Mumbai 400056, India
| | - Bala Prabhakar
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS Deemed to be University, Vile-Parle (W), Mumbai 400056, India
| | - Ambikanandan Misra
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS Deemed to be University, Vile-Parle (W), Mumbai 400056, India
| | - Khushwant S Yadav
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS Deemed to be University, Vile-Parle (W), Mumbai 400056, India.
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26
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Rasheed N, Anand R, Maddox M, Reyes C. Refractory pembrolizumab immunotherapy-related colitis requiring biological therapy in an inactive HBcAb carrier. BMJ Case Rep 2023; 16:e256675. [PMID: 37751983 PMCID: PMC10533673 DOI: 10.1136/bcr-2023-256675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
Immune checkpoint inhibitors are a class of cancer immunotherapy, with a constellation of side effects that require early recognition and management. We present a patient with metastatic adenocarcinoma started on pembrolizumab a month prior, who was admitted to the hospital for bloody diarrhoea. He underwent flexible sigmoidoscopy with biopsy proven grade 3 immune-mediated diarrhoea and colitis. He developed progressively worsening diarrhoea despite appropriate intravenous corticosteroids therapy, and initiation of corticosteroid-sparing therapy was complicated by discovery of hepatitis B core antibodies indicating a chronic hepatitis B carrier state. We discuss our work-up of new onset haemorrhagic diarrhoea in a patient on immunotherapy for metastatic non-small cell lung cancer, as well as a review of current guidelines for antiviral prophylaxis in these patients.
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Affiliation(s)
- Nidaa Rasheed
- Internal Medicine, University of California San Francisco, Fresno, California, USA
| | - Rajan Anand
- Department of Gastroenterology, University of California San Francisco Fresno, Fresno, California, USA
| | - Mark Maddox
- Department of Medical Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Candice Reyes
- Department of Rheumatology, University of California San Francisco, Fresno, California, USA
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Saji A, Chopra M, Jacob J, Altan M, Alhalabi O, Shah AY, Qiao W, Wang Y, Thomas A. Implementing an immunotherapy toxicity (IOTOX) GI service improves outcomes in patients with immune-mediated diarrhea and colitis. J Cancer Res Clin Oncol 2023; 149:5841-5852. [PMID: 36585982 PMCID: PMC9803881 DOI: 10.1007/s00432-022-04504-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/29/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but can lead to GI toxicity, termed immune-mediated diarrhea and colitis (IMDC). Standardization of IMDC management and early GI consultation is imperative to control symptoms and prevent delays in cancer care. Therefore, we implemented an inpatient algorithm and a focused IOTOX GI service to measure outcomes. METHODS Patients who received ICIs and were hospitalized with severe IMDC were grouped into a pre-interventional cohort in 2017, followed by implementation of the standardized algorithm in 2018, and then a post-interventional cohort of patients in 2019. Clinical data and patient outcomes were compared using univariate and multivariate analysis to determine the morbidity, and overall survival. RESULTS Our sample comprised 126 hospitalized patients with IMDC, with 59 patients in the pre-interventional 2017 cohort, and 67 patients in the post-interventional 2019 cohort. We found no significant differences in the clinical severity of IMDC symptoms between the two cohorts (p = 1.03) or median time from ICI exposure to development of IMDC (p = 0.495, respectively). After implementing the standardized algorithm, we observed higher rates of GI consultation (p < 0.001) in the post-treatment group. Patients in the post-treatment cohort showed decreased time to clinical remission (4 vs 10 days, p = 0.046), higher rate of GI follow-up after hospital discharge (p = 0.038), fewer hospital re-admissions (p = 0.002), and significantly fewer recurrences of IMDC symptoms (p = 0.002). Overall survival was significantly higher for at least 2 years in patients who followed with GI post-discharge compared to those without follow-up (p = 0.003). CONCLUSION Prompt GI consultation and monitoring of IMDC using a regimented approach can provide efficacious management, decrease time to clinical remission of symptoms, decrease re-admissions to the hospital, and improve overall patient outcomes.
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Affiliation(s)
- Alice Saji
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX 77079 USA
| | - Maneera Chopra
- Division of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jake Jacob
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX USA
| | - Mehmet Altan
- Department of Thoracic, Head and Neck Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX USA
| | - Omar Alhalabi
- Department of Genitourinary Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX USA
| | - Amishi Yogesh Shah
- Department of Genitourinary Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX USA
| | - Wei Qiao
- Department of Biostatistics, The University of M.D. Anderson Cancer Center, Houston, TX USA
| | - Yinghong Wang
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX 77079 USA
| | - Anusha Thomas
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX 77079 USA
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28
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Li C, Wang L, Sun D, Yao T, Xian X, Cheng Y. Colitis induced by PD-1 inhibitor combined with platinum-containing dual drug chemotherapy in Lewis mice and its mechanism. J Cancer Res Ther 2023; 19:939-944. [PMID: 37675720 DOI: 10.4103/jcrt.jcrt_2078_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Aims To explore the occurrence and possible mechanism of colitis in Lewis mice treated with PD-1 inhibitor combined with platinum-containing dual drug chemotherapy. Subjects and Methods A Lewis lung cancer model of C57BL/6 mice was established, randomly divided into the treatment group (group C, PD-1 inhibitor + Carboplatin (CARB) + Pemetrexed (PEM)) and model group (group B, normal saline), and a control group (group A, normal saline) was set up. Observe the changes in tumor-free weight, tumor volume, disease activity index (DAI), colon histopathology, identify serum interleukin (IL)-10, interferon (IFN)-γ, the expression of claudin-1, and occludin mRNA in the colon in each animals. Results Compared with group A, the tumor-free weight of mice in B decreased (P < 0.001), the content of IL-10 in serum increased (P < 0.01), the content of IFN-γ in serum decreased (P < 0.01). Compared with group B, the transplanted tumor volume in C was reduced (P < 0.05), DAI scores of D4 (P < 0.001), and D7 (P < 0.001) were increased, colonic histopathology analysis showed that colitis occurred, serum IL-10 content was decreased (P < 0.05), IFN-γ content was increased (P < 0.05), and the mRNA expression of claudin-1 (P < 0.05) and occludin (P < 0.05) was reduced. Conclusions This treatment can inhibit the growth of transplanted tumors but will cause colitis in Lewis mice. The impairment of intestinal barrier function following administration cause an imbalance in the expression of pro-inflammatory and anti-inflammatory factors in the colon, thus causing colitis.
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Affiliation(s)
- Chunhai Li
- Department of Radiology, The Qilu Hospital of Shandong University, Jinan Shandong, China
| | - Lixin Wang
- Department of School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong, China
| | - Daqian Sun
- Department of Radiology, The Qilu Hospital of Shandong University, Jinan Shandong, China
| | - Tianxiao Yao
- Department of Radiology, The Qilu Hospital of Shandong University, Jinan Shandong, China
| | - Xiuying Xian
- Department of Interventional Department, Jinan Central Hospital, Jinan Shandong, China
| | - Yufeng Cheng
- Department of Radiotherapy, The Qilu Hospital of Shandong University, Jinan, Shandong, China
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Xiao Q, Li X, Liu C, Jiang Y, He Y, Zhang W, Azevedo HS, Wu W, Xia Y, He W. Improving cancer immunotherapy via co-delivering checkpoint blockade and thrombospondin-1 downregulator. Acta Pharm Sin B 2023; 13:3503-3517. [PMID: 37655330 PMCID: PMC10465872 DOI: 10.1016/j.apsb.2022.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/24/2022] [Accepted: 07/07/2022] [Indexed: 12/13/2022] Open
Abstract
The use of checkpoint-blockade antibodies is still restricted in several malignancies due to the modest efficacy, despite considerable success in anti-tumor immunotherapy. The poor response of cancer cells to immune destruction is an essential contributor to the failure of checkpoint therapy. We hypothesized that combining checkpoint therapy with natural-product chemosensitizer could enhance immune response. Herein, a targeted diterpenoid derivative was integrated with the checkpoint blockade (anti-CTLA-4) to improve immunotherapy using thermosensitive liposomes as carriers. In vivo, the liposomes enabled the co-delivery of the two drug payloads into the tumor. Consequently, the regulatory T cell proliferation was restrained, the cytotoxic T cell infiltration was enhanced, and the profound immunotherapeutic effect was achieved. In addition, the immunotherapeutic effect of another clinically used checkpoint antibody, anti-PD-1, also benefited from the diterpenoid derivative. Of note, our mechanism study revealed that the targeted diterpenoid derivative increased the sensitivity of cancer cells to immune attack via THBS1 downregulation and the resultant destruction of THBS1-CD47 interaction. Collectively, co-delivering THBS1 inhibitor and checkpoint blockade is promising to boost cancer immunotherapy. We first time discovered that THBS1 suppression could strengthen checkpoint therapy.
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Affiliation(s)
- Qingqing Xiao
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Xiaotong Li
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Chang Liu
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Yuxin Jiang
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Yonglong He
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Wanting Zhang
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Helena S. Azevedo
- School of Engineering and Materials Science, Institute of Bioengineering, Queen Mary University of London, London E1 4NS, UK
| | - Wei Wu
- School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Yuanzheng Xia
- Jiangsu Key Laboratory of Bioactive Natural Product Research and State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 210009, China
| | - Wei He
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
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Robinson MD, McNamara MG, Clouston HW, Sutton PA, Hubner RA, Valle JW. Patients Undergoing Systemic Anti-Cancer Therapy Who Require Surgical Intervention: What Surgeons Need to Know. Cancers (Basel) 2023; 15:3781. [PMID: 37568597 PMCID: PMC10417541 DOI: 10.3390/cancers15153781] [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: 06/13/2023] [Revised: 07/15/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
As part of routine cancer care, patients may undergo elective surgery with the aim of long-term cure. Some of these patients will receive systemic anti-cancer therapy (SACT) in the neoadjuvant and adjuvant settings. The majority of patients, usually with locally advanced or metastatic disease, will receive SACT with palliative intent. These treatment options are expanding beyond traditional chemotherapy to include targeted therapies, immunotherapy, hormone therapy, radionuclide therapy and gene therapy. During treatment, some patients will require surgical intervention on an urgent or emergency basis. This narrative review examined the evidence base for SACT-associated surgical risk and the precautions that a surgical team should consider in patients undergoing SACT.
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Affiliation(s)
- Matthew D. Robinson
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
| | - Mairéad G. McNamara
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Hamish W. Clouston
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Paul A. Sutton
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Richard A. Hubner
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Juan W. Valle
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
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Meybodi SM, Farasati Far B, Pourmolaei A, Baradarbarjastehbaf F, Safaei M, Mohammadkhani N, Samadani AA. Immune checkpoint inhibitors promising role in cancer therapy: clinical evidence and immune-related adverse events. Med Oncol 2023; 40:243. [PMID: 37453930 DOI: 10.1007/s12032-023-02114-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
The advent of immune checkpoint inhibitors (ICIs) has led to noteworthy progressions in the management of diverse cancer types, as evidenced by the pioneering "ipilimumab" medication authorized by US FDA in 2011. Importantly, ICIs agents have demonstrated encouraging potential in bringing about transformation across diverse forms of cancer by selectively targeting the immune checkpoint pathways that are exploited by cancerous cells for dodging the immune system, culminating in progressive and favorable health outcomes for patients. The primary mechanism of action (MOA) of ICIs involves blocking inhibitory immune checkpoints. There are three approved categories including Programmed Death (PD-1) inhibitors (cemiplimab, nivolumab, and pembrolizumab), Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) (Ipilimumab), and Programmed Death-Ligand 1 (PDL-1) (Avelumab). Although ICIs promisingly increase therapeutic response and cancer survival rates, using ICIs has demonstrated some limitations including autoimmune reactions and toxicities, requiring close monitoring. The present review endeavors to explicate the underlying principles of the MOA and pharmacokinetics of the approved ICIs in the realm of cancer induction, including an appraisal of their level of practice-based evidence.
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Affiliation(s)
| | - Bahareh Farasati Far
- Department of Chemistry, Iran University of Science and Technology, Tehran, 1684613114, Iran.
| | - Ali Pourmolaei
- Babol Noshirvani University of Technology, Shariati Ave, Babol, Mazandaran, Iran
| | - Farid Baradarbarjastehbaf
- Faculty of Pharmacy, Department of Pharmaceutical Technology and Biopharmacy, University of Pécs, Pécs, Hungary
| | - Maryam Safaei
- Department of Pharmacology, Faculty of Pharmacy, Eastern Mediterranean University, 99628, Famagusta, Turkey
| | - Niloufar Mohammadkhani
- Department of Clinical Biochemistry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Samadani
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran.
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Terrin M, Migliorisi G, Dal Buono A, Gabbiadini R, Mastrorocco E, Quadarella A, Repici A, Santoro A, Armuzzi A. Checkpoint Inhibitor-Induced Colitis: From Pathogenesis to Management. Int J Mol Sci 2023; 24:11504. [PMID: 37511260 PMCID: PMC10380448 DOI: 10.3390/ijms241411504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
The advent of immunotherapy, specifically of immune checkpoint inhibitors (ICIs), for the treatment of solid tumors has deeply transformed therapeutic algorithms in medical oncology. Approximately one-third of patients treated with ICIs may de velop immune-related adverse events, and the gastrointestinal tract is often affected by different grades of mucosal inflammation. Checkpoint inhibitors colitis (CIC) presents with watery or bloody diarrhea and, in the case of severe symptoms, requires ICIs discontinuation. The pathogenesis of CIC is multifactorial and still partially unknown: anti-tumor activity that collaterally effects the colonic tissue and the upregulation of specific systemic inflammatory pathways (i.e., CD8+ cytotoxic and CD4+ T lymphocytes) are mainly involved. Many questions remain regarding treatment timing and options, and biological treatment, especially with anti-TNF alpha, can be offered to these patients with the aim of rapidly resuming oncological therapies. CIC shares similar pathogenesis and aspects with inflammatory bowel disease (IBD) and the use of ICI in IBD patients is under evaluation. This review aims to summarize the pathogenetic mechanism underlying CIC and to discuss the current evidenced-based management options, including the role of biological therapy, emphasizing the relevant clinical impact on CIC and the need for prompt recognition and treatment.
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Affiliation(s)
- Maria Terrin
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Giulia Migliorisi
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Arianna Dal Buono
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
| | - Roberto Gabbiadini
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
| | - Elisabetta Mastrorocco
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Alessandro Quadarella
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Medical Oncology and Haematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Armuzzi
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
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Kazemzadeh K, Behrouzieh S, Rezaei N. Shedding light on the side effects of immunotherapies used for leukemia: an updated review of the literature. Expert Rev Anticancer Ther 2023; 23:1193-1204. [PMID: 37812581 DOI: 10.1080/14737140.2023.2267760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Leukemia is an abnormal clonal development of leukemic cells originating from the bone marrow, which is widely known for its significant prevalence and mortality rate. Chemotherapy, surgery, radiation, and combination therapies have been its routine therapeutic methods; however, the advent of cancer immunotherapy is known as revolutionary for its higher efficacy and lesser toxicity. AREAS COVERED Immunotherapy boosts the body's immune system by using components from other living organisms. Although immunotherapy seems to be safer than chemotherapy, many studies have noticed different immune-related side effects in various body systems (e.g. cardiovascular, neurologic) which we have reviewed in this investigation as the main goal. We tried to describe immunotherapy-related side effects in human body systems in detail. EXPERT OPINION Being aware of these side effects leads to better clinical decision-making for each individual, and a one-step-ahead management in case of occurrence. We also briefly discussed the role of immunotherapy in treating leukemia as one of the most prevalent cancers in children and tried to emphasize that it is crucial to monitor adverse events as they may remain obscure until adolescence.
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Affiliation(s)
- Kimia Kazemzadeh
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Network of Neurosurgery and Artificial Intelligence (NONAI), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Sadra Behrouzieh
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Neurosurgery and Artificial Intelligence (NONAI), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Wang SJ, Dougan SK, Dougan M. Immune mechanisms of toxicity from checkpoint inhibitors. Trends Cancer 2023; 9:543-553. [PMID: 37117135 PMCID: PMC10330206 DOI: 10.1016/j.trecan.2023.04.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/30/2023]
Abstract
Immunotherapy has changed the treatment landscape for cancer over the past decade. Inhibitors of the immune checkpoint proteins cytotoxic T lymphocyte antigen (CTLA)-4, programmed death (PD)-1, and PD ligand 1 (PD-L1) can induce durable remissions in a subset of patients with metastatic disease. However, these treatments can be limited by inflammatory toxicities that can affect any organ system in the body and in some cases can be life threatening. Considerable progress has been made in understanding the drivers of these toxicities as well as effective management strategies. Further research into understanding the molecular and cellular mechanisms that drive toxicity will enable better prediction of toxicity and development of optimized therapies for these toxicities that avoid interfering with antitumor immunity. In this review, we discuss our current understanding of the inflammatory toxicities from immune checkpoint inhibitors (ICIs) and propose optimal treatment strategies for these toxicities.
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Affiliation(s)
- S Jennifer Wang
- Department of Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stephanie K Dougan
- Department of Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
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Desmedt V, Jauregui-Amezaga A, Fierens L, Aspeslagh S, Dekervel J, Wauters E, Peeters M, Sabino J, Crapé L, Somers M, Hoorens A, Dutré J, Lobatón T. Position statement on the management of the immune checkpoint inhibitor-induced colitis via multidisciplinary modified Delphi consensus. Eur J Cancer 2023; 187:36-57. [PMID: 37116287 DOI: 10.1016/j.ejca.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 02/10/2023] [Accepted: 03/23/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION The use of immune checkpoint inhibitors (ICIs) in cancer immunotherapy has shown increased overall survival in a wide range of cancer types with the associated risk of developing severe immune-mediated adverse events, commonly involving the gastrointestinal tract. AIM The aim of this position statement is to provide an updated practice advice to the gastroenterologists and oncologists on the diagnosis and management of ICI-induced gastrointestinal toxicity. METHODOLOGY The evidence reviewed in this paper includes a comprehensive search strategy of English language publications. Consensus was reached using a three-round modified Delphi methodology and approved by the members of the Belgian Inflammatory Bowel Disease Research and Development Group (BIRD), Belgian Society of Medical Oncology (BSMO), Belgian group of Digestive Oncology (BGDO), and Belgian Respiratory Society (BeRS). CONCLUSIONS The management of ICI-induced colitis requires an early multidisciplinary approach. A broad initial assessment is necessary (clinical presentation, laboratory markers, endoscopic and histologic examination) to confirm the diagnosis. Criteria for hospitalisation, management of ICIs, and initial endoscopic assessment are proposed. Even if corticosteroids are still considered the first-line therapy, biologics are recommended as an escalation therapy and as early treatment in patients with high-risk endoscopic findings.
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Affiliation(s)
- Valérie Desmedt
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Belgium
| | - Aranzazu Jauregui-Amezaga
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Belgium; Laboratory of Experimental Medicine and Pediatrics (LEMP), Division of Gastroenterology-Hepatology, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium.
| | - Liselotte Fierens
- Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Catholic University of Leuven, Belgium
| | | | - Jeroen Dekervel
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Belgium
| | - Els Wauters
- Respiratory Oncology Unit (Pulmonology), University Hospitals KU Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Marc Peeters
- Department of Digestive Oncology, University Hospital Antwerp, Belgium
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Belgium
| | - Lara Crapé
- Department of Gastroenterology, Algemeen Stedelijk Ziekenhuis Aalst, Belgium
| | - Michael Somers
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Belgium
| | - Anne Hoorens
- Department of Pathology, University Hospital Ghent, Belgium
| | - Joris Dutré
- Department of Gastroenterology, Ziekenhuis Netwerk Antwerpen Jan Palfijn, Belgium
| | - Triana Lobatón
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
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Halsey TM, Thomas AS, Hayase T, Ma W, Abu-Sbeih H, Sun B, Parra ER, Jiang ZD, DuPont HL, Sanchez C, El-Himri R, Brown A, Flores I, McDaniel L, Turrubiates MO, Hensel M, Pham D, Watowich SS, Hayase E, Chang CC, Jenq RR, Wang Y. Microbiome alteration via fecal microbiota transplantation is effective for refractory immune checkpoint inhibitor-induced colitis. Sci Transl Med 2023; 15:eabq4006. [PMID: 37315113 PMCID: PMC10759507 DOI: 10.1126/scitranslmed.abq4006] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/19/2023] [Indexed: 06/16/2023]
Abstract
Immune checkpoint inhibitors (ICIs) target advanced malignancies with high efficacy but also predispose patients to immune-related adverse events like immune-mediated colitis (IMC). Given the association between gut bacteria with response to ICI therapy and subsequent IMC, fecal microbiota transplantation (FMT) represents a feasible way to manipulate microbial composition in patients, with a potential benefit for IMC. Here, we present a large case series of 12 patients with refractory IMC who underwent FMT from healthy donors as salvage therapy. All 12 patients had grade 3 or 4 ICI-related diarrhea or colitis that failed to respond to standard first-line (corticosteroids) and second-line immunosuppression (infliximab or vedolizumab). Ten patients (83%) achieved symptom improvement after FMT, and three patients (25%) required repeat FMT, two of whom had no subsequent response. At the end of the study, 92% achieved IMC clinical remission. 16S rRNA sequencing of patient stool samples revealed that compositional differences between FMT donors and patients with IMC before FMT were associated with a complete response after FMT. Comparison of pre- and post-FMT stool samples in patients with complete responses showed significant increases in alpha diversity and increases in the abundances of Collinsella and Bifidobacterium, which were depleted in FMT responders before FMT. Histologically evaluable complete response patients also had decreases in select immune cells , including CD8+ T cells, in the colon after FMT when compared with non-complete response patients (n = 4). This study validates FMT as an effective treatment strategy for IMC and gives insights into the microbial signatures that may play a critical role in FMT response.
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Affiliation(s)
- Taylor M. Halsey
- Graduate School of Biomedical Sciences, Microbiology and Infectious Diseases, The University of Texas MD Anderson Cancer Center UTHealth Houston; Houston, Texas, USA
| | - Anusha S. Thomas
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Tomo Hayase
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Weijie Ma
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
- Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University; Wuhan, Hubei Province, People’s Republic of China
| | - Hamzah Abu-Sbeih
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
- Department of Internal Medicine, University of Missouri; Kansas City, Missouri, USA
| | - Baohua Sun
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Edwin Roger Parra
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Zhi-Dong Jiang
- Center for Infectious Diseases, School of Public Health, The University of Texas; Houston, Texas, USA
| | - Herbert L. DuPont
- Center for Infectious Diseases, School of Public Health, The University of Texas; Houston, Texas, USA
- Kelsey Research Foundation; Houston, Texas, USA
| | - Christopher Sanchez
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Rawan El-Himri
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Alexandria Brown
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Ivonne Flores
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Lauren McDaniel
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Miriam Ortega Turrubiates
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | | | - Dung Pham
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Stephanie S. Watowich
- Department of Immunology, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Eiko Hayase
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Chia-Chi Chang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Robert R. Jenq
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center; Houston, Texas, USA
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Peixoto RD, Ferreira AR, Cleary JM, Fogacci JP, Vasconcelos JP, Jácome AA. Risk of Cancer in Inflammatory Bowel Disease and Pitfalls in Oncologic Therapy. J Gastrointest Cancer 2023; 54:357-367. [PMID: 35288863 DOI: 10.1007/s12029-022-00816-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD), represented by ulcerative colitis and Crohn's disease, is an idiopathic condition caused by a dysregulated immune response to host intestinal microflora, leading to chronic relapsing intestinal inflammation. Individuals with IBD are more prone to die from several diseases, including cancer. METHODS An extensive search was conducted of PubMed using the following medical subject heading-"inflammatory bowel disease" OR "Crohn's disease" OR "ulcerative colitis" AND "cancer." RESULTS In this review article, we discuss the oncogenic mechanisms and genomics of colitis-associated colorectal cancer. Beyond this, we describe the multiple other malignancies that IBD patients are at risk for, discuss caveats in the screening and diagnosis of those cancers, and shed light on pitfalls on the management and treatment of cancer in IBD patients. CONCLUSION Patients, caregivers, and health professionals who deal with IBD must be educated on how to identify warning signs so that cancers can be diagnosed and treated as early as possible.
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Losurdo G, Angelillo D, Favia N, Sergi MC, Di Leo A, Triggiano G, Tucci M. Checkpoint Inhibitor-Induced Colitis: An Update. Biomedicines 2023; 11:biomedicines11051496. [PMID: 37239166 DOI: 10.3390/biomedicines11051496] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
Immunotherapy with immune checkpoint inhibitors (ICIs) nowadays has indications for several solid tumors. The current targets for ICIs are CTLA-4, PD-1, and PD-L1 receptors. Despite the clinical advantages derived from ICIs, a variety of side effects are linked to overstimulation of the immune system. Among these, ICI-related colitis is one of the most common, with a disabling impact on the patient. Diarrhea, abdominal pain, abdominal distension, cramping, and hematochezia are the most common ICI enterocolitis presenting symptoms. The most frequently used grading system for assessment of the severity of ICI enterocolitis is called the Common Terminology Criteria for Adverse Events (CTCAE) grading. With regard to the histological picture, there is no specific feature; however, microscopic damage can be classified into five types: (1) acute active colitis, (2) chronic active colitis, (3) microscopic colitis-like, (4) graft-versus-host disease-like, and (5) other types. Supportive therapy (oral hydration, a bland diet without lactose or caffeine, and anti-diarrheal agents) is indicated in mild colitis. Symptomatic treatment alone or with loperamide, a low-fiber diet, and spasmolytics are recommended for low-grade diarrhea. In more severe cases, corticosteroid treatment is mandatory. In refractory cases, off-label use of biological therapies (infliximab or vedolizumab) was proposed.
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Affiliation(s)
- Giuseppe Losurdo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Daniele Angelillo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Nicolas Favia
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Maria Chiara Sergi
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Policlinico di Bari, 70124 Bari, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Giacomo Triggiano
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Policlinico di Bari, 70124 Bari, Italy
| | - Marco Tucci
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Policlinico di Bari, 70124 Bari, Italy
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
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Mallio CA, Bernetti C, Cea L, Buoso A, Stiffi M, Vertulli D, Greco F, Zobel BB. Adverse Effects of Immune-Checkpoint Inhibitors: A Comprehensive Imaging-Oriented Review. Curr Oncol 2023; 30:4700-4723. [PMID: 37232813 DOI: 10.3390/curroncol30050355] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/22/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023] Open
Abstract
Immune-checkpoint inhibitors (ICIs) are immunomodulatory monoclonal antibodies, which increase antitumor immunity of the host and facilitate T-cell-mediated actions against tumors. These medications have been used in recent years as a weapon against advanced stage malignancies, such as melanoma, renal cell carcinoma, lymphoma, small or non-small cell lung cancer, and colorectal cancer. Unfortunately, they are not free from possible adverse effects (immune-related adverse events-irAEs) that mainly affect skin, gastrointestinal, hepatic, and endocrine systems. Early diagnosis of irAEs is essential to correctly and rapidly manage patients, with ICIs suspension and therapies administration. Deep knowledge of the imaging and clinical patterns of irAEs is the key to promptly rule out other diagnoses. Here, we performed a review of the radiological signs and differential diagnosis, based on the organ involved. The aim of this review is to provide guidance to recognize the most significant radiological findings of the main irAEs, based on incidence, severity, and the role of imaging.
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Affiliation(s)
- Carlo Augusto Mallio
- Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Department of Medicine and Surgery, Research Unit of Radiology, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Caterina Bernetti
- Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Department of Medicine and Surgery, Research Unit of Radiology, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Laura Cea
- Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Department of Medicine and Surgery, Research Unit of Radiology, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Andrea Buoso
- Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Department of Medicine and Surgery, Research Unit of Radiology, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Massimo Stiffi
- Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Department of Medicine and Surgery, Research Unit of Radiology, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Daniele Vertulli
- Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Department of Medicine and Surgery, Research Unit of Radiology, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Federico Greco
- Unità Operativa Complessa Diagnostica per Immagini Territoriale Aziendale, Cittadella della Salute Azienda Sanitaria Locale di Lecce, Piazza Filippo Bottazzi, 73100 Lecce, Italy
| | - Bruno Beomonte Zobel
- Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Department of Medicine and Surgery, Research Unit of Radiology, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
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Chen YC, Jaffer M, Zhou L, Moslehi J, Forsyth PA, Fecher LA. A Brain, A Heart, and the Courage: Balancing Benefit and Toxicity of Immunotherapy in Melanoma. Am Soc Clin Oncol Educ Book 2023; 43:e390594. [PMID: 37229626 DOI: 10.1200/edbk_390594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The overall survival of advanced melanoma has improved dramatically. Immunotherapies, specifically checkpoint inhibitors, have played a large role in this improvement. These agents have also shown benefit in the adjuvant setting, are approved for treatment of resected stage II, III, and IV melanoma, and play an evolving role in the neoadjuvant setting. Although generally well tolerated, immune-related adverse events occur and can be severe. Here we focus on some severe and potentially long term toxicities, including cardiovascular and neurologic toxicities. Our understanding of the acute and long-term toxicities of immune checkpoint inhibitors continues to evolve. Oncologists must continue to balance cancer risk and treatment-related toxicities.
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Affiliation(s)
- Yen-Chou Chen
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
- Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Muhammad Jaffer
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
| | - Lylybell Zhou
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Javid Moslehi
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Peter A Forsyth
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
- Department of Oncology, Moffitt Cancer Center and University of South Florida, Tampa, FL
| | - Leslie A Fecher
- Rogel Cancer Center at the University of Michigan, Ann Arbor, MI
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Alruwaii ZI, Montgomery EA. Gastrointestinal and Hepatobiliary Immune-related Adverse Events: A Histopathologic Review. Adv Anat Pathol 2023; 30:230-240. [PMID: 37037419 DOI: 10.1097/pap.0000000000000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Immune checkpoint inhibitors have been increasingly used to treat various malignant neoplasms. Despite their superior efficacy in treating certain ones, their global immune-activation effect leads to systemic side effects, referred to as immune-related adverse events. Immune-related adverse events affect a variety of organs, including the skin, gastrointestinal, hepatobiliary, and endocrine organs. Gastrointestinal tract immune-related adverse events present with a wide range of symptoms with variable severity, which may lead to treatment interruption and administration of immunosuppression therapy in many cases. Histopathologic changes are diverse, overlapping with many other conditions. Therefore, recognizing these changes is crucial in diagnosing immune-related adverse events. This review discusses the pathologic manifestations of gastrointestinal immune-related adverse events and discusses the primary differential diagnoses.
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Shirwaikar Thomas A, Hanauer S, Wang Y. Immune Checkpoint Inhibitor Enterocolitis vs Idiopathic Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2023; 21:878-890. [PMID: 36270617 DOI: 10.1016/j.cgh.2022.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 02/07/2023]
Abstract
Immune checkpoint inhibitors have revolutionized management of advanced malignancies. However, their use is frequently complicated by immune related adverse events (irAEs), immune checkpoint inhibitor enterocolitis (IMEC) being the most common toxicity. IMEC is a distinct form of bowel inflammation that is highly reminiscent of idiopathic inflammatory bowel disorders (Crohn's disease, ulcerative colitis, and microscopic colitis). In this review, we highlight the similarities and differences in the pathophysiology, clinical presentation, evaluation, and management of these overlapping immune inflammatory bowel disorders. IMEC is an inflammatory bowel disease-like irAE that occurs as an outcome of disruption of intestinal immune surveillance and gut dysbiosis. Clinical and endoscopic presentation of both entities is strikingly similar, which often guides management. Though well established in inflammatory bowel disease, little is known about the long term outcomes of IMEC.
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Affiliation(s)
- Anusha Shirwaikar Thomas
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Hanauer
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Wetwittayakhlang P, Tselekouni P, Al-Jabri R, Bessissow T, Lakatos PL. The Optimal Management of Inflammatory Bowel Disease in Patients with Cancer. J Clin Med 2023; 12:jcm12062432. [PMID: 36983432 PMCID: PMC10056442 DOI: 10.3390/jcm12062432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Patients with inflammatory bowel disease (IBD) have an increased risk of cancer secondary to chronic inflammation and long-term use of immunosuppressive therapy. With the aging IBD population, the prevalence of cancer in IBD patients is increasing. As a result, there is increasing concern about the impact of IBD therapy on cancer risk and survival, as well as the effects of cancer therapies on the disease course of IBD. Managing IBD in patients with current or previous cancer is challenging since clinical guidelines are based mainly on expert consensus. Evidence is rare and mainly available from registries or observational studies. In contrast, excluding patients with previous/or active cancer from clinical trials and short-term follow-up can lead to an underestimation of the cancer or cancer recurrence risk of approved medications. The present narrative review aims to summarize the current evidence and provide practical guidance on the management of IBD patients with cancer.
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Affiliation(s)
- Panu Wetwittayakhlang
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Paraskevi Tselekouni
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Reem Al-Jabri
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- Department of Internal Medicine and Oncology, Semmelweis University, 1085 Budapest, Hungary
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Boulagnon-Rombi C, Dufour C, Chatelain D. [Drug induced gastro-intestinal tract lesions: A pathologist point of view]. Ann Pathol 2023:S0242-6498(23)00045-7. [PMID: 36868901 DOI: 10.1016/j.annpat.2023.02.002] [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: 12/02/2022] [Revised: 01/31/2023] [Accepted: 02/08/2023] [Indexed: 03/05/2023]
Abstract
The number of drugs available to clinicians, especially targeted therapies, grows continuously. Some drugs are known to cause frequent digestive adverse effects, which may affect the gastro-intestinal tract in a diffuse or localized manner. Some treatments may leave relatively pathognomonic deposits, but histological lesions of iatrogenic origin are mostly non-specific. The diagnostic and etiological approach is often complex because of these non-specific aspects and also because (1) a single type of drug may cause different histological lesions, (2) different drugs may cause identical histological lesions, (3) the patient may receive different drugs, and (4) drug-induced lesions may mimic other pathological entities such as inflammatory bowel disease, celiac disease, or graft versus host disease. The diagnosis of iatrogenic gastrointestinal tract injury therefore requires close anatomic-clinical correlation. The iatrogenic origin can only be formally established if the symptomatology improves when the incriminating drug is stopped. This review aims to present the different histological patterns of gastrointestinal tract iatrogenic lesions, the potentially incriminate drugs, as well as the histological signs to look for in order to help the pathologist to distinguish an iatrogenic injury from another pathology of the gastrointestinal tract.
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Affiliation(s)
- Camille Boulagnon-Rombi
- Service de pathologie, centre hospitalier universitaire de Reims, 51092 Reims cedex, France; Université de Reims Champagne Ardenne, CNRS, MEDyC UMR 7369, 51097 Reims, France.
| | - Charlotte Dufour
- Institut de pathologie, centre de biologie pathologie, centre hospitalier universitaire de Lille, 59000 Lille, France
| | - Denis Chatelain
- Service d'anatomie pathologique du CHU d'Amiens, site Nord, 80080 Amiens, France
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45
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Drug-induced digestive tract injury: decoding some invisible offenders. Hum Pathol 2023; 132:135-148. [PMID: 35714837 DOI: 10.1016/j.humpath.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/09/2022] [Indexed: 02/07/2023]
Abstract
There is an ever-growing list of pharmacological agents, several of which are attributed to cause clinically significant gastrointestinal (GI) injury. Many patients present with significant but nonspecific symptoms, that in conjunction with the absence of relevant drug history on the requisition slip can make the histopathologic diagnosis challenging. To complicate this, although some drugs have relatively characteristic histopathologic features (such as doxycycline), there exist many other drugs that exhibit wide and varying spectra of histopathologic findings (such as immune checkpoint inhibitors or olmesartan) and have histomorphologic overlap with many other commonly encountered disease entities. This review discusses the histopathologic features of some relatively recently described drugs causing GI tract injury, namely doxycycline, tacrolimus, mycophenolate, immune checkpoint inhibitors, and olmesartan. We also discuss the common mimics in histopathologic differential and some pearls that can help distinguish GI tract injury induced by the aforementioned drugs from its mimics. Awareness of the wide spectra of histopathologic changes associated with these drugs is crucial for practicing pathologists, to avoid misdiagnosis and guiding the clinician for an optimal patient management, which usually involves modifying or discontinuing the offending drug. Needless to say, once a diagnosis of drug-induced injury is suspected, clinicopathologic correlation including corroboration with the drug history is of utmost importance as is the exclusion of dual pathology in these patients.
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Sakurai K, Katsurada T, Nishida M, Omotehara S, Fukushima S, Otagiri S, Nagashima K, Onishi R, Takagi R, Komatsu Y, Sakamoto N. Characteristics and usefulness of transabdominal ultrasonography in immune-mediated colitis. Intest Res 2023; 21:126-136. [PMID: 35860848 PMCID: PMC9911272 DOI: 10.5217/ir.2021.00166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 06/06/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND/AIMS The usefulness of ultrasonography (US) in diseases of the gastrointestinal tract has been reported recently. This prospective study aimed to determine the features of US findings in immune-mediated colitis (IMC), an adverse event induced by immune checkpoint inhibitor, and examine the correlation between US findings, colonoscopy (CS) findings, and severity of colitis. METHODS We studied patients examined using CS and US upon suspicion of IMC in Hokkaido University Hospital between April 2018 and February 2021. Endoscopic findings of IMC were assessed using the Ulcerative Colitis Endoscopic Index of Severity (UCEIS). The severity of US findings in IMC was evaluated using US grade, which is the ultrasonographic grading scale in ulcerative colitis. Bowel wall thickness and the intensity of the color Doppler signal were also analyzed. Severity of colitis was evaluated using Common Terminology Criteria for Adverse Events (CTCAE) grade version 5. RESULTS Fourteen patients with IMC were enrolled. The US findings were bowel wall thickening, loss of stratification, ulceration and increased blood flow signal. The US grade was moderately correlated with the UCEIS (r=0.687, p=0.009) and CTCAE grade (r=0.628, p=0.035). Bowel wall thickness and UCEIS (r=0.628, p=0.020), as well as color Doppler signal grade and CTCAE grade (r=0.724, p=0.008), were significantly correlated. CONCLUSIONS US findings in IMC were mainly similar to those of ulcerative colitis, but there were some findings that were characteristic only of IMC. Significant correlation was found between US findings, CS findings, and severity of colitis. Hence, US could be useful for the evaluation of IMC.
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Affiliation(s)
- Kensuke Sakurai
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Takehiko Katsurada
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan,Correspondence to Takehiko Katsurada, Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Kita-15, Nishi-7 Kita-ku, Sapporo 060-8638, Japan. Tel: +81-11-716-1161, Fax: +81-11-706-7999, E-mail:
| | - Mutsumi Nishida
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan,Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Satomi Omotehara
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan,Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Shinya Fukushima
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Shinsuke Otagiri
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Kazunori Nagashima
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Reizo Onishi
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Ryo Takagi
- Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshito Komatsu
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan,Depatment of Cancer Chemotherapy, Hokkaido University Hospital Cancer Center, Sapporo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
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Abstract
Gastrointestinal toxicities secondary to immune checkpoint inhibitors are very frequent. Because in some instances this can be severe or fatal, it is essential to be able to identify immune-related adverse events rapidly. Prompt initiation of systemic immunosuppression can improve outcomes. A biopsy is often necessary to confirm the diagnosis of immune-related adverse events. Moderate or severe irAEs need an interruption of ICI. After the resolution of the toxicities, the rechallenge of immune checkpoint inhibitors must be discussed case by case.
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Berry P, Kotha S, Zen Y, Papa S, El Menabawey T, Webster G, Joshi D, Heneghan M. Immune checkpoint inhibitor-related cholangiopathy: Novel clinicopathological description of a multi-centre cohort. Liver Int 2023; 43:147-154. [PMID: 35704341 DOI: 10.1111/liv.15340] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/25/2022] [Accepted: 06/12/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS Cholestatic liver dysfunction is common in immune-related hepatitis (irH) during treatment with immune checkpoint inhibitors (CPI) for malignancy. We investigated the spectrum of bile duct injury and associated natural history in this cohort. METHOD Clinical, laboratory, radiological and histopathological data in patients with evidence of bile duct injury during CPI treatment from 2018 to 2020 was collected in three tertiary hospitals. RESULTS In this study, ten patients with confirmed bile duct disease were identified. Pembrolizumab was most commonly implicated (8/10). Median CPI cycles prior to bile duct injury was 6. Median alanine aminotransferase and alkaline phosphatase were 225 U/L and 1549 U/L respectively. Clinical jaundice was seen in 6/10 and radiological evidence of bile duct pathology in 8/10. Of five patients, who had liver biopsy, three cases (including two cases with normal MRCP) showed primary sclerosing cholangitis (PSC) like changes with periductal fibrosis. All patients were treated first-line with prednisolone following cessation of CPI, three with mycophenolate mofetil and one with tacrolimus, with clinical response in four patients. Five patients died after a mean follow-up of 27 weeks; cause of death was primarily related to progression of malignancy. CONCLUSION Within this heterogeneous cohort, we identified that CPI-related cholangiopathy responded poorly to immunosuppression and potentially progressed to bile duct loss. Thorough radiological and histological assessment is recommended, as identification of the cholangiopathy-associated phenotype may permit more informed advice regarding prognosis. Further data is required to determine detailed immunological characterisation in order to identify individuals at an increased risk of developing cholangiopathy.
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Affiliation(s)
- Philip Berry
- Department of Hepatology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Sreelakshmi Kotha
- Department of Hepatology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Yoh Zen
- Department of Histopathology, King's College Hospital, London, UK
| | - Sophie Papa
- Department of Oncology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Tareq El Menabawey
- Department of hepato-biliary medicine, University college London Hospital, London, UK
| | - George Webster
- Department of hepato-biliary medicine, University college London Hospital, London, UK
| | - Deepak Joshi
- Department of Hepatology, King's college Hospital, London, UK
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Saji A, Chopra M, Jacob J, Altan M, Alhalabi O, Shah AY, Qiao W, Wang Y, Thomas A. Implementing an immunotherapy toxicity (IOTOX) GI service improves outcomes in patients with immune-mediated diarrhea and colitis. J Cancer Res Clin Oncol 2022. [PMID: 36585982 DOI: 10.1007/s00432-022-04545-6.10.1007/s00432-022-04545-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
PURPOSE Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but can lead to GI toxicity, termed immune-mediated diarrhea and colitis (IMDC). Standardization of IMDC management and early GI consultation is imperative to control symptoms and prevent delays in cancer care. Therefore, we implemented an inpatient algorithm and a focused IOTOX GI service to measure outcomes. METHODS Patients who received ICIs and were hospitalized with severe IMDC were grouped into a pre-interventional cohort in 2017, followed by implementation of the standardized algorithm in 2018, and then a post-interventional cohort of patients in 2019. Clinical data and patient outcomes were compared using univariate and multivariate analysis to determine the morbidity, and overall survival. RESULTS Our sample comprised 126 hospitalized patients with IMDC, with 59 patients in the pre-interventional 2017 cohort, and 67 patients in the post-interventional 2019 cohort. We found no significant differences in the clinical severity of IMDC symptoms between the two cohorts (p = 1.03) or median time from ICI exposure to development of IMDC (p = 0.495, respectively). After implementing the standardized algorithm, we observed higher rates of GI consultation (p < 0.001) in the post-treatment group. Patients in the post-treatment cohort showed decreased time to clinical remission (4 vs 10 days, p = 0.046), higher rate of GI follow-up after hospital discharge (p = 0.038), fewer hospital re-admissions (p = 0.002), and significantly fewer recurrences of IMDC symptoms (p = 0.002). Overall survival was significantly higher for at least 2 years in patients who followed with GI post-discharge compared to those without follow-up (p = 0.003). CONCLUSION Prompt GI consultation and monitoring of IMDC using a regimented approach can provide efficacious management, decrease time to clinical remission of symptoms, decrease re-admissions to the hospital, and improve overall patient outcomes.
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Affiliation(s)
- Alice Saji
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX, 77079, USA
| | - Maneera Chopra
- Division of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jake Jacob
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mehmet Altan
- Department of Thoracic, Head and Neck Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX, USA
| | - Omar Alhalabi
- Department of Genitourinary Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX, USA
| | - Amishi Yogesh Shah
- Department of Genitourinary Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX, USA
| | - Wei Qiao
- Department of Biostatistics, The University of M.D. Anderson Cancer Center, Houston, TX, USA
| | - Yinghong Wang
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX, 77079, USA
| | - Anusha Thomas
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX, 77079, USA.
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Germline genetic variation and predicting immune checkpoint inhibitor induced toxicity. NPJ Genom Med 2022; 7:73. [PMID: 36564402 PMCID: PMC9789157 DOI: 10.1038/s41525-022-00345-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/07/2022] [Indexed: 12/25/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) therapy has revolutionised the treatment of various cancer types. ICIs reinstate T-cell function to elicit an anti-cancer immune response. The resulting immune response can however have off-target effects which manifest as autoimmune type serious immune-related adverse events (irAE) in ~10-55% of patients treated. It is currently challenging to predict both who will experience irAEs and to what severity. Identification of patients at high risk of serious irAE would revolutionise patient care. While the pathogenesis driving irAE development is still unclear, host genetic factors are proposed to be key determinants of these events. This review presents current evidence supporting the role of the host genome in determining risk of irAE. We summarise the spectrum and timing of irAEs following treatment with ICIs and describe currently reported germline genetic variation associated with expression of immuno-modulatory factors within the cancer immunity cycle, development of autoimmune disease and irAE occurrence. We propose that germline genetic determinants of host immune function and autoimmune diseases could also explain risk of irAE development. We also endorse genome-wide association studies of patients being treated with ICIs to identify genetic variants that can be used in polygenic risk scores to predict risk of irAE.
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