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Malvaso A, Giglio P, Diamanti L, Gastaldi M, Vegezzi E, Pace A, Bini P, Marchioni E. Unravelling the Acute, Chronic and Steroid-Refractory Management of High-Grade Neurological Immune-Related Adverse Events: A Call to Action. Brain Sci 2024; 14:764. [PMID: 39199458 PMCID: PMC11352216 DOI: 10.3390/brainsci14080764] [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: 06/15/2024] [Revised: 07/17/2024] [Accepted: 07/25/2024] [Indexed: 09/01/2024] Open
Abstract
Rare side effects of immune-checkpoint inhibitors (ICIs) are known as neurological immune-related adverse events (n-irAEs). Typically, n-irAEs affect the peripheral nervous system, primarily presenting as myositis, polyradiculoneuropathy, or cranial neuropathy. Less commonly, they impact the central nervous system, resulting in encephalitis, meningitis, or myelitis. High-grade n-irAEs managing and recognizing remains challenging, considering the risk of mortality and long-term disability. To date, strong scientific data are lacking to support the management of high-grade clinical forms. We performed a systematic literature search, selecting all articles describing high-grade steroid-resistance n-irAEs. and we reported them in a practical review. Specifically, current recommendations advise stopping ICI use and beginning corticosteroid treatment. Our findings highlighted that in steroid-resistant n-irAEs, it should be recommended to quickly escalate to plasma exchange (PLEX) and/or intravenously immunoglobulins (IVIg), usually in association with other immunosuppressants. Furthermore, newer evidence supports the use of drugs that may specifically block inflammation without reducing the anti-tumour effect of ICIs. In this practical review, we provide new evidence regarding the therapeutic approach of high-grade n-irAEs, particularly in steroid-resistant cases. We would also stress the importance of informing the scientific community of the discrepancy between current guidelines and clinical evidence in these rare forms of pathology.
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Affiliation(s)
- Antonio Malvaso
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.M.); (P.G.)
- Neuroimmunology Research Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy;
| | - Pierpaolo Giglio
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.M.); (P.G.)
| | - Luca Diamanti
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Matteo Gastaldi
- Neuroimmunology Research Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy;
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Elisa Vegezzi
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Andrea Pace
- IRCCS Regina Elena, Istituto Nazionale Tumori, 00144 Rome, Italy;
| | - Paola Bini
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Enrico Marchioni
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
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Gritsch D, Valencia-Sanchez C. Drug-related immune-mediated myelopathies. Front Neurol 2022; 13:1003270. [PMID: 36247761 PMCID: PMC9557103 DOI: 10.3389/fneur.2022.1003270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Iatrogenic immune-mediated inflammatory disorders of the spinal cord are an uncommon but potentially severe complication of drug therapy for several human diseases. Particularly the introduction of novel biological agents in the treatment of systemic inflammatory disorders and cancer immunotherapy have led to a significant increase in immune-related adverse events of the central nervous system (CNS). The use of Tumor necrosis factor alpha (TNF-alpha) inhibitors in rheumatic and inflammatory bowel diseases has been associated with demyelinating and other inflammatory CNS conditions, including myelitis. The introduction of immune checkpoint inhibitors in the treatment of several human malignancies has led to an increase in drug-induced immune-related adverse events including in the CNS. Other drugs that have been associated with immune-mediated myelitis include tyrosine-kinase inhibitors and chimeric antigen receptor (CAR) T Cell therapy. A high degree of suspicion is necessary when diagnosing these conditions, as early diagnosis and treatment is crucial in preventing further neurological damage and disability. The treatment of drug-induced inflammatory myelitis typically involves administration of high-dose intravenous corticosteroids, however additional immunosuppressive agents may be required in severe or refractory cases. While most cases are monophasic and remit following discontinuation of the offending agent, chronic immunosuppressive therapy may be indicated in cases with a progressive or relapsing disease course or when a diagnosis of a specific underlying neuro-inflammatory disorder is made. Outcomes are generally favorable, however depend on the specific therapeutic agent used, the clinical presentation and patient factors. In this review we aim to describe the clinical characteristics, imaging findings and management for the most common forms of iatrogenic immune-mediated myelopathies.
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Affiliation(s)
- David Gritsch
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, United States
| | - Cristina Valencia-Sanchez
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, United States
- *Correspondence: Cristina Valencia-Sanchez
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Januel E, Perol L, Arrivé L, Alamowitch S, Fain O, Mekinian A. Anti-PD1-R checkpoint inhibitor related severe relapsing myelitis. Acta Neurol Belg 2021; 121:1855-1857. [PMID: 32661739 DOI: 10.1007/s13760-020-01434-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/03/2020] [Indexed: 01/24/2023]
Affiliation(s)
- Edouard Januel
- Neurology Department, Saint Antoine Hospital, APHP, Sorbonne Université, Paris, France
| | - Louis Perol
- Service de médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3D), Hôpital Saint-Antoine, AP-HP, Sorbonne Université, Paris, France
| | - Lionel Arrivé
- Radiology Department, Saint Antoine Hospital, APHP, Sorbonne Université, Paris, France
| | - Sonia Alamowitch
- Neurology Department, Saint Antoine Hospital, APHP, Sorbonne Université, Paris, France
| | - Olivier Fain
- Service de médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3D), Hôpital Saint-Antoine, AP-HP, Sorbonne Université, Paris, France
| | - Arsene Mekinian
- Service de médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3D), Hôpital Saint-Antoine, AP-HP, Sorbonne Université, Paris, France.
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Brzezinska BN, Higgins RV, Rungruang B. Guillain-Barre Syndrome in a patient with uterine adenocarcinoma undergoing treatment with immune-checkpoint inhibitor therapy: A case report and review of the literature. Gynecol Oncol Rep 2021; 36:100739. [PMID: 33748382 PMCID: PMC7967007 DOI: 10.1016/j.gore.2021.100739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/10/2021] [Accepted: 02/23/2021] [Indexed: 12/11/2022] Open
Abstract
Use of immune checkpoint inhibitors in treatment of gynecologic malignancies is increasing. Immune checkpoint inhibitors such as pembrolizumab may cause a variety of immune-related adverse effects. Guillain-Barre Syndrome is a rare but potentially fatal adverse effect that requires prompt evaluation and treatment.
Background Use of immune checkpoint inhibitors in treatment of gynecologic malignancies is increasing. Rare, but potentially fatal, immune-related neurologic adverse events may occur as a result of treatment. Case A 72 year old female with recurrent metastatic uterine adenocarcinoma received pembrolizumab and lenvatinib combination therapy. Following her second dose of pembrolizumab, the patient developed multiple neurologic symptoms. She was ultimately diagnosed with Guillain-Barre Syndrome based on neurologic evaluation with imaging, serum studies, and cerebrospinal fluid analysis. The patient was successfully treated with high-dose intravenous corticosteroids and intravenous immunoglobulin. Conclusion Neurologic complications related to immune checkpoint inhibitor therapy are rare. It is imperative for gynecologic oncologists to be familiar with potentially fatal hazards of therapy to allow for rapid diagnosis and treatment.
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Affiliation(s)
- Bogna N Brzezinska
- Division of Gynecologic Oncology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Robert V Higgins
- Division of Gynecologic Oncology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Bunja Rungruang
- Division of Gynecologic Oncology, Medical College of Georgia at Augusta University, Augusta, GA, United States
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Gatson NTN, Makary M, Bross SP, Vadakara J, Maiers T, Mongelluzzo GJ, Leese EN, Brimley C, Fonkem E, Mahadevan A, Sarkar A, Panikkar R. Case series review of neuroradiologic changes associated with immune checkpoint inhibitor therapy. Neurooncol Pract 2020; 8:247-258. [PMID: 34055372 DOI: 10.1093/nop/npaa079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
While immuno-oncotherapy (IO) has significantly improved outcomes in the treatment of systemic cancers, various neurological complications have accompanied these therapies. Treatment with immune checkpoint inhibitors (ICIs) risks multi-organ autoimmune inflammatory responses with gastrointestinal, dermatologic, and endocrine complications being the most common types of complications. Despite some evidence that these therapies are effective to treat central nervous system (CNS) tumors, there are a significant range of related neurological side effects due to ICIs. Neuroradiologic changes associated with ICIs are commonly misdiagnosed as progression and might limit treatment or otherwise impact patient care. Here, we provide a radiologic case series review restricted to neurological complications attributed to ICIs, anti-CTLA-4, and PD-L-1/PD-1 inhibitors. We report the first case series dedicated to the review of CNS/PNS radiologic changes secondary to ICI therapy in cancer patients. We provide a brief case synopsis with neuroimaging followed by an annotated review of the literature relevant to each case. We present a series of neuroradiological findings including nonspecific parenchymal and encephalitic, hypophyseal, neural (cranial and peripheral), meningeal, cavity-associated, and cranial osseous changes seen in association with the use of ICIs. Misdiagnosis of radiologic abnormalities secondary to neurological immune-related adverse events can impact patient treatment regimens and clinical outcomes. Rapid recognition of various neuroradiologic changes associated with ICI therapy can improve patient tolerance and adherence to cancer therapies.
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Affiliation(s)
- Na Tosha N Gatson
- Cancer Institute, Geisinger Medical Center, Danville, PA, USA.,Neuroscience Institute, Geisinger Medical Center, Danville, PA, USA.,School of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA.,Banner MD Anderson Cancer Center, Neuro-Oncology Division, Phoenix, AZ, USA
| | - Mina Makary
- Cancer Institute, Geisinger Medical Center, Danville, PA, USA
| | - Shane P Bross
- Neuroscience Institute, Geisinger Medical Center, Danville, PA, USA.,School of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Joseph Vadakara
- Cancer Institute, Geisinger Medical Center, Danville, PA, USA
| | - Tristan Maiers
- Enterprise Pharmacy, Geisinger Medical Center, Danville, PA, USA
| | | | - Erika N Leese
- Neuroscience Institute, Geisinger Medical Center, Danville, PA, USA
| | - Cameron Brimley
- Department of Neurosurgery, Geisinger Medical Center, Danville, PA, USA
| | - Ekokobe Fonkem
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Anand Mahadevan
- Department of Radiation Oncology, Geisinger Medical Center, Danville, PA, USA
| | - Atom Sarkar
- Department of Neurosurgery, Global Neurosciences Institute, Drexel University School of Medicine, Philadelphia, PA, USA
| | - Rajiv Panikkar
- Cancer Institute, Geisinger Medical Center, Danville, PA, USA
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Inflammatory Myeloradiculitis Secondary to Pembrolizumab: A Case Report and Literature Review. Case Rep Oncol Med 2020; 2020:8819296. [PMID: 32908747 PMCID: PMC7450342 DOI: 10.1155/2020/8819296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 11/17/2022] Open
Abstract
Immune checkpoint inhibitors are the most important new medications in oncology and include inhibitors of programmed cell death protein-1 (PD-1) such as Pembrolizumab, Nivolumab, and Cemiplimab. These anticancer agents prevent tumour immune evasion and have been associated with a range of immune-related adverse events (irAEs) including those involving the nervous system. In this case report and literature review, we present the first case of inflammatory myeloradiculitis secondary to Pembrolizumab. We also summarise the characteristics, treatment, and outcomes of other cases reported in the literature which include a component of myelitis. Finally, we make general recommendations on management.
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