1
|
Abdel-Wahab N, Suarez-Almazor ME. Rheumatic adverse events of immune checkpoint inhibitors in cancer immunotherapy. Expert Rev Clin Immunol 2024; 20:873-893. [PMID: 38400840 DOI: 10.1080/1744666x.2024.2323966] [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: 11/03/2023] [Accepted: 02/19/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION The advent of immune checkpoint inhibitors (ICIs) in cancer treatment has marked a transformative era, albeit tempered by immune-related adverse events (irAEs), including those impacting the musculoskeletal system. The lack of precise epidemiologic data on rheumatic irAEs is attributed to factors such as potential underrecognition, underreporting in clinical trials, and the tendency to overlook manifestations without immediate life-threatening implications, further complicating the determination of accurate incidence rates, while the complete understanding of the mechanisms driving rheumatic irAEs remains elusive. AREAS COVERED This literature review comprehensively examines rheumatic irAEs in cancer patients undergoing ICI therapy, encompassing epidemiology, risk factors, mechanisms, clinical manifestations, and current management guidance for prevalent conditions such as inflammatory arthritis, polymyalgia rheumatica, and myositis. Less frequent rheumatic and musculoskeletal irAEs are also explored, alongside insights into ongoing clinical trials testing therapeutic and preventive strategies for irAEs. A thorough literature search on Medline and the National Cancer Institute Clinical Trials Database was conducted up to October 2023 to compile relevant information. EXPERT OPINION In light of the evolving landscape of cancer immunotherapy, there is a compelling need for prospective longitudinal studies to enhance understanding and inform clinical management strategies for rheumatic irAEs.
Collapse
Affiliation(s)
- Noha Abdel-Wahab
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine; and Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Rheumatology and Rehabilitation, Assiut University Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Maria E Suarez-Almazor
- Department of Health Services Research; and Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
2
|
Shawer R, Solomon A. Adverse effects of anti-cancer biologics on the ocular surface. Curr Opin Allergy Clin Immunol 2024:00130832-990000000-00136. [PMID: 38963724 DOI: 10.1097/aci.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE OF REVIEW Cancer immunotherapy is one of the most emerging and rapidly growing fields.Ocular side effects associated with these therapies are common and can be present in up to 70% of patients.The cornea may be involved in different pathogenic mechanisms triggered by different immunotherapeutic agents, and corneal disease varies from mild symptoms to severe corneal ulceration and melting with visual loss.We aimed to review the incidence, mechanism, and management of ocular surface side effects in cancer patients receiving immunotherapy. RECENT FINDINGS With the recent use of immunotherapeutic agents in cancer patients, in particular immune checkpoint inhibitors (ICIs) and epidermal growth factor receptor (EGFR) inhibitors, ocular surface and corneal involvement are common side effects.These patients can be at risk of sight threatening complications that warrant prompt diagnosis and careful monitoring and management. SUMMARY Immunotherapy- related corneal complications in cancer patients are associated with a decreased quality of life. Prompt recognition and an interdisciplinary approach between ophthalmologists and oncologists are crucial to handle immune related ocular adverse events in these patients, in order to maintain ocular surface integrity and avoid a vision threatening complication.
Collapse
Affiliation(s)
- Riham Shawer
- Department of Ophthalmology, Hadassah-Hebrew University Medical Centre
- St. John Eye Hospital, Jerusalem, Israel
| | - Abraham Solomon
- Department of Ophthalmology, Hadassah-Hebrew University Medical Centre
| |
Collapse
|
3
|
Pasoto SG, Franco AS, Silva CA, Bonfa E. Sicca syndrome/Sjögren's disease associated with cancer immunotherapy: a narrative review on clinical presentation, biomarkers, and management. Expert Rev Clin Immunol 2024:1-19. [PMID: 38903050 DOI: 10.1080/1744666x.2024.2370327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 06/17/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION Almost one-quarter of immune checkpoint inhibitor (ICI) recipients experience sicca syndrome, while Sjögren's disease (SjD) is estimated at 0.3-2.5%, possibly underreported. AREAS COVERED This narrative review (Medline/Embase until January/31/2024) addresses the pathophysiology, incidence, demographic/clinical features, biomarkers, labial salivary gland biopsy (LSGB), fulfillment of the idiopathic SjD (iSjD) classificatory criteria, differential diagnosis, and management of sicca syndrome/SjD associated with ICIs. EXPERT OPINION SjD associated with ICIs is underdiagnosed, since studies that performed the mandatory SjD investigation identified that 40-60% of patients with sicca syndrome associated with ICIs meet the iSjD classificatory criteria. LSGB played a fundamental role in recognizing these cases, as most of them had negative anti-Ro/SS-A antibody. Despite the finding of focal lymphocytic sialoadenitis in LSGB samples mimicking iSjD, immunohistochemical analysis provided novel evidence of a distinct pattern for sicca syndrome/SjD associated with ICIs compared to iSjD. The former has scarcity of B lymphocytes, which are a hallmark of iSjD. Additionally, patients with sicca syndrome/SjD associated with ICIs have demographical/clinical/serological and treatment response dissimilarities compared to iSjD. Dryness symptoms are more acute in the former than in iSjD, with predominance of xerostomia over xerophthalmia, and partial/complete response to glucocorticoids. Dryness symptoms in ICI-treated patients warrant prompt SjD investigation.
Collapse
Affiliation(s)
- Sandra Gofinet Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - André Silva Franco
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Clovis Artur Silva
- Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Eloisa Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| |
Collapse
|
4
|
Gómez-Puerta JA, Gente K, Katsumoto TR, Leipe J, Reid P, van Binsbergen WH, Suarez-Almazor ME. Mimickers of Immune Checkpoint Inhibitor-induced Inflammatory Arthritis. Rheum Dis Clin North Am 2024; 50:161-179. [PMID: 38670719 DOI: 10.1016/j.rdc.2024.01.002] [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: 04/28/2024]
Abstract
The differential diagnosis of inflammatory arthritis as an immune-related adverse event can be challenging as patients with cancer can present with musculoskeletal symptoms that can mimic arthritis because of localized or generalized joint pain. In addition, immune checkpoint inhibitors can exacerbate joint conditions such as crystal-induced arthritis or osteoarthritis, or induce systemic disease that can affect the joints such as sarcoidosis. This distinction is important as the treatment of these conditions can be different from that of immune-related inflammatory arthritis.
Collapse
Affiliation(s)
- José A Gómez-Puerta
- Department of Rheumatology, Hospital Clínic; University of Barcelona, Escala 11-2, Barcelona, Villarroel 170, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Karolina Gente
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Tamiko R Katsumoto
- Division of Immunology and Rheumatology, Department of Medicine, 300 Pasteur Drive Suite H305, Stanford, CA 94305, USA
| | - Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim, Heidelberg 68167, Germany
| | - Pankti Reid
- Division of Rheumatology, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Wouter H van Binsbergen
- Department of Rheumatology & Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ (AMC) & De Boelelaan 1117, Amsterdam 1081 HV (VUmc), The Netherlands
| | - Maria E Suarez-Almazor
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| |
Collapse
|
5
|
Harnden K, Di Matteo A, Howell K, Mankia K. Rapid onset pembrolizumab-induced inflammatory arthritis diagnosed using musculoskeletal ultrasound. BMJ Case Rep 2024; 17:e258706. [PMID: 38663895 PMCID: PMC11043772 DOI: 10.1136/bcr-2023-258706] [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: 04/28/2024] Open
Abstract
Immune checkpoint inhibitors have revolutionised the treatment of cancer. While very effective, they commonly cause a wide spectrum of immune-related adverse events. These immune-related adverse events can be fatal and often have significant effects on quality of life. They therefore require prompt recognition and management. We report the case of a woman presenting with widespread joint pain and stiffness 6 hours after her first pembrolizumab infusion. She had no joint swelling on physical examination but an ultrasound scan revealed widespread musculoskeletal inflammation, confirming the diagnosis of inflammatory arthritis. To the best of our knowledge, this is the fastest reported inflammatory arthritis onset following immune checkpoint inhibitor treatment. It highlights the importance of timely imaging in patients on immune checkpoint inhibitors who present with new non-specific musculoskeletal pain. Her symptoms improved dramatically with intramuscular triamcinolone injection.
Collapse
Affiliation(s)
- Kate Harnden
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
| | - Andrea Di Matteo
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Kulveer Mankia
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
6
|
Nicoletti MM, Crisci E, Cosenza V, Riccardi C, Campitiello MR, Ruggiero D, Berrino PM, Docimo G, Scavone C. Immune Checkpoint Inhibitors and Scleroderma: Data from the European Pharmacovigilance Database. Drugs Real World Outcomes 2024; 11:33-41. [PMID: 37907712 DOI: 10.1007/s40801-023-00399-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) can be commonly associated with the occurrence of immune-related adverse drug reactions (irADRs), which can involve any tissue and organ. ICI-induced skin toxicities are common irADRs and they can be a consequence of a rheumatologic ADR, such as in the case of scleroderma. A recent literature review reported that scleroderma and scleroderma mimics represent a group of disorders with significant morbidity that have been described during ICIs' use. OBJECTIVE AND METHODS Considering the clinical significance of scleroderma cases, the present study aimed to analyze the occurrence of these events in patients receiving ICIs by describing data from individual case safety reports (ICSRs) retrieved from the European spontaneous reporting system, EudraVigilance (EV). RESULTS Until February 2023, 70 ICSRs with at least one ICI as the suspected drug and at least one preferred term (PT) related to scleroderma cases were retrieved from the EV. Pembrolizumab was reported as suspected in 41 ICSRs, nivolumab in 25 ICSRs, ipilimumab in 8 ICSRs and atezolizumab in 3 ICSRs. Patients who experienced scleroderma cases were adults, and no differences were found in terms of sex distribution. Scleroderma cases were mainly classified as serious, while the outcome was mainly reported as favorable. The most reported PTs were scleroderma and morphea. CONCLUSIONS Considering the seriousness of ICI-induced scleroderma cases and the recent marketing authorization of some ICIs, we believe that further high-quality clinical studies should be conducted on this topic to better estimate the impact of these events in patients with cancer.
Collapse
Affiliation(s)
| | - Erminia Crisci
- Department of Plastic Aesthetic and Reconstructive Surgery, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
| | - Vincenzo Cosenza
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies (DiSTABiF), University of Campania "Luigi Vanvitelli", 81100, Caserta, Italy
| | - Consiglia Riccardi
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, 80138, Naples, Italy
| | - Maria Rosaria Campitiello
- Department of Obstetrics and Gynaecology and Physiopathology of Human Reproduction, ASL Salerno, Salerno, Italy
| | - Donatella Ruggiero
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, 80138, Naples, Italy
| | - Pasquale Maria Berrino
- Department of Specialized Medicine, Diagnostic and Experimental, University of Bologna "Alma Mater Studiorum", Bologna, Italy
| | - Giovanni Docimo
- Department of Medical and Advanced Surgical Sciences, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
| | - Cristina Scavone
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy.
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, 80138, Naples, Italy.
| |
Collapse
|
7
|
Vitzthum von Eckstaedt H, Singh A, Reid P, Trotter K. Immune Checkpoint Inhibitors and Lupus Erythematosus. Pharmaceuticals (Basel) 2024; 17:252. [PMID: 38399467 PMCID: PMC10892070 DOI: 10.3390/ph17020252] [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: 10/24/2023] [Revised: 01/16/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are the standard of care for a growing number of malignancies. Unfortunately, they are associated with a broad range of unique toxicities that mimic the presentations of primary autoimmune conditions. These adverse events are termed immune-related adverse events (irAEs), of which ICI-lupus erythematosus (ICI-LE) constitutes a small percentage. Our review aims to describe the available literature on ICI-LE and ICI treatment for patients with pre-existing lupus. Most diagnoses of ICI-LE had findings of only cutaneous lupus; four diagnoses of ICI-LE had systemic lupus manifestations. Over 90% (27 of 29) of cases received anti-PD-1/PDL-1 monotherapy, 1 received combination therapy, and 1 received only anti-CTLA-4 treatment. About three-fourths (22 of 29 or 76%) of patients with ICI-lupus were managed with topical steroids, 13 (45%) received hydroxychloroquine, and 10 (34%) required oral corticosteroids. In our case series, none of the patients with pre-existing lupus receiving ICI therapy for cancer had a flare of their lupus, but few had de novo irAE manifestations, all of which were characterized as low-grade. The review of the literature yielded seven ICI-LE flares from a total of 27 patients with pre-existing lupus who received ICI. Most flares were manageable without need for ICI cessation.
Collapse
Affiliation(s)
| | - Arohi Singh
- College of the University of Chicago, University of Chicago, Chicago, IL 60637, USA;
| | - Pankti Reid
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago Medicine, Chicago, IL 60637, USA
- Department of Medicine, Section of Rheumatology, University of Chicago Medicine, Chicago, IL 60637, USA;
| | - Kimberly Trotter
- Department of Medicine, Section of Rheumatology, University of Chicago Medicine, Chicago, IL 60637, USA;
| |
Collapse
|
8
|
Lemarchant B, Mortier L, Lannoy J, Dubucquoi S, Zephir H. Evaluation of a self-questionnaire to screen for neurological complications associated with immunological checkpoint inhibitors: Are we missing something? Rev Neurol (Paris) 2023; 179:1095-1102. [PMID: 37714728 DOI: 10.1016/j.neurol.2023.03.029] [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: 01/08/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Immunological checkpoint inhibitors (ICI) have led to a therapeutic revolution in the management of many cancers and indications are increasing. Neurological complications seem to have a profile quite distinct from that of toxicities related to chemotherapy, although it is possible that some manifestations remain under-reported or misdiagnosed. OBJECTIVES (i) To evaluate the value of a self-questionnaire in screening for neurological ICI-related complications. (ii) To investigate whether, apart from the subacute complications described in the literature, neurological complications of more insidious onset might occur. METHOD Patients followed in dermatology department for skin cancers treated with ICI, completed every infusion a neurological screening auto-questionnaire. Patients were selected for a neurological expertise based on the questionnaire's data. RESULTS In total, 149 patients completed≥1 questionnaire, with a median delay of 174 days from the start of treatment. A total of 229 questionnaires were completed between July 2019 and December 2019. 38 patients were identified for a neurological consultation. None of these patients had a neurological event attributable to ICI. During the follow-up, only one patient had a neurological event related to ICI, which was not revealed by the questionnaire. DISCUSSION Neurological signs in ICI-treated-skin-cancer context are more often due to tumoral progression. Neurological complications of ICI remain rare and unpredictable. The systematic neurological questionnaire has not been shown to be useful in this context. These results highlight the need to educate patients about possible subacute signs that should lead to contact the treating physicians and the need for a close cooperation between dermatologists/oncologists and neurologists.
Collapse
Affiliation(s)
- B Lemarchant
- Unité de neurologie inflammatoire, CRC-SEP, Department of Neurology, CHU de Lille, hôpital Roger-Salengro, Lille, France; Inserm U1172, université de Lille, Lille, France.
| | - L Mortier
- Department of Dermatology, CHU de Lille, hôpital Huriez, Lille, France; Inserm U1189, université de Lille, Lille, France
| | - J Lannoy
- Department of Neurology, centre hospitalier Lens, Lens, France
| | - S Dubucquoi
- Inserm, U1286-INFINITE: Institute for Translational Research in Inflammation, CHU de Lille, université de Lille, Lille, France
| | - H Zephir
- Unité de neurologie inflammatoire, CRC-SEP, Department of Neurology, CHU de Lille, hôpital Roger-Salengro, Lille, France; Inserm U1172, université de Lille, Lille, France
| |
Collapse
|
9
|
Small A, Lowe K, Wechalekar MD. Immune checkpoints in rheumatoid arthritis: progress and promise. Front Immunol 2023; 14:1285554. [PMID: 38077329 PMCID: PMC10704353 DOI: 10.3389/fimmu.2023.1285554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
Rheumatoid arthritis (RA) is one of the most prevalent autoimmune inflammatory conditions, and while the mechanisms driving pathogenesis are yet to be completely elucidated, self-reactive T cells and immune checkpoint pathways have a clear role. In this review, we provide an overview of the importance of checkpoint pathways in the T cell response and describe the involvement of these in RA development and progression. We discuss the relationship between immune checkpoint therapy in cancer and autoimmune adverse events, draw parallels with the involvement of immune checkpoints in RA pathobiology, summarise emerging research into some of the lesser-known pathways, and the potential of targeting checkpoint-related pathways in future treatment approaches to RA management.
Collapse
Affiliation(s)
- Annabelle Small
- Department of Rheumatology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Katie Lowe
- Department of Rheumatology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Mihir D Wechalekar
- Department of Rheumatology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Rheumatology, Flinders Medical Centre, Adelaide, SA, Australia
| |
Collapse
|
10
|
Martel J, Hanania HL, Patel AB. Immune checkpoint inhibitor-induced cutaneous toxicities: a review of histopathologic and clinical features. Hum Pathol 2023; 140:144-172. [PMID: 37141978 DOI: 10.1016/j.humpath.2023.04.016] [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: 02/01/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) represent an emerging treatment option for a variety of cancer types. Through inhibition of programmed cell death protein 1 (PD-1), programmed cell death ligand 1 (PD-L1), and/or cytotoxic lymphocyte-associated antigen-4 (CTLA-4), ICIs activate the host's immune system causing a heightened anti-tumor response. However, off-target effects of ICIs can result in numerous different immune-related cutaneous adverse events (irCAEs). Beyond impacting quality of life, irCAEs can lead to dose limitations or discontinuation of anti-cancer therapies. Correct diagnosis is necessary for expedient and appropriate management. Skin biopsies are often performed to increase diagnostic accuracy and guide clinical management. An extensive literature review was performed using the PubMed database to identify the reported clinical and histopathologic features of irCAEs. This comprehensive review primarily details the histopathologic features of various irCAEs reported to date. Clinical presentation and immunopathogenesis are also discussed in relation to histopathology.
Collapse
Affiliation(s)
- Julianna Martel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Anisha B Patel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA.
| |
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW Immune check point inhibitors (ICIs) are a unique class of cancer treatments that harness the body's innate antitumor response. Although these medications have transformed oncology care, they also lead to generalized immune activation that can result in toxicities across a spectrum of organ systems called immune-related adverse events. This article reviews the most common rheumatologic immune-related adverse events and their management. RECENT FINDINGS Inflammatory arthritis, polymyalgia rheumatic, sicca symptoms, systemic sclerosis, myositis, and vasculitis have all been reported as ICI adverse events. Treatment includes nonsteroidal anti-inflammatory drugs, glucocorticoids, traditional DMARDs, and biologics. SUMMARY Rheumatologists have an important role in the management of patients with rheumatologic immune-related adverse events. Working with our oncology colleagues, we can help manage rheumatologic immune-related adverse events while optimally preserving ICI's antitumor effects.
Collapse
Affiliation(s)
- Melissa Defoe
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | |
Collapse
|
12
|
Garbarino MC, Manzano N, Messina O, Zylberman M. Rheumatological adverse events secondary to immune checkpoint inhibitors. REUMATOLOGÍA CLÍNICA (ENGLISH EDITION) 2023; 19:215-222. [PMID: 37005129 DOI: 10.1016/j.reumae.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/29/2022] [Indexed: 04/03/2023]
Abstract
The first experiences with a group of drugs called immune checkpoint inhibitors for the treatment of cancer were described in 2010. They are currently used in many tumours, with successful survival outcomes but a new profile of adverse events. This new spectrum of immune-mediated toxicities includes an exaggerated inflammatory response of T lymphocyte and the development of autoimmune diseases or similar pathologies. Of these, of particular note are the rheumatological toxicities. This review aims to alert internists and rheumatologists to their recognition and clinical management.
Collapse
Affiliation(s)
- María Cecilia Garbarino
- Departamento de Medicina Interna, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina; Sección Reumatología, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina.
| | - Natalia Manzano
- Departamento de Medicina Interna, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Osvaldo Messina
- Sección Reumatología, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina
| | - Marcelo Zylberman
- Departamento de Medicina Interna, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina; Departamento de Medicina Interna, Instituto Alexander Fleming, Buenos Aires, Argentina
| |
Collapse
|
13
|
Muhaj F, Karri PV, Moody W, Brown A, Patel AB. Mucocutaneous adverse events to immune checkpoint inhibitors. FRONTIERS IN ALLERGY 2023; 4:1147513. [PMID: 36938327 PMCID: PMC10017442 DOI: 10.3389/falgy.2023.1147513] [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: 01/18/2023] [Accepted: 02/15/2023] [Indexed: 03/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy. Since the approval of ipilimumab in 2011, a total of nine ICIs have gained indications for various solid and hematologic malignancies. The expanding use of ICIs in oncology underscores the need for diagnosis and treatment expertise in immune related adverse events (irAE). Cutaneous toxicities are the earliest and most common irAE in this class of therapy. In addition to the more frequent reactions including vitiligo, lichenoid dermatitis, psoriasiform dermatitis, other less common skin toxicities including bullous dermatoses, neutrophilic dermatoses, and autoimmune dermato-rheumatologic diseases have been reported. Even though less than 3% of cutaneous irAEs (irCAEs) are classified as grade 3 or higher events, irCAEs can greatly impact quality of life. Appropriate management of irCAEs is critical to avoid unwarranted interruptions or discontinuation of lifesaving immunotherapy.
Collapse
Affiliation(s)
- Fiorinda Muhaj
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Padmavathi V. Karri
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Dermatology, University of Texas Health Science Center- Houston, Houston, TX, United States
| | - Wylie Moody
- Department of Internal Medicine, HCA Houston Healthcare West, Houston, TX, United States
| | - Alexandria Brown
- Department of Internal Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Anisha B. Patel
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Correspondence: Anisha B. Patel
| |
Collapse
|
14
|
Expert Clinical Management of Severe Immune-Related Adverse Events: Results from a Multicenter Survey on Hot Topics for Management. J Clin Med 2022; 11:jcm11205977. [PMID: 36294298 PMCID: PMC9604376 DOI: 10.3390/jcm11205977] [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: 08/26/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
There are differences in recommendations for the management of immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICIs). To assess the real-world management of irAEs, three surveys regarding ICI-induced hepatitis (IIH), renal irAEs, and myositis were developed and sent to experts in each area. Fifty-six surveys were completed (17 IIH, 20 renal irAEs, and 19 myositis). All experts agreed on performing imaging in every suspected case of severe IIH. Sixty-five percent agreed on performing a liver biopsy in patients not responding to corticosteroids. The most common indication for corticosteroid use (59%) was for severe IIH not improving after discontinuation of ICIs. Additionally, 60% of the experts agreed on performing a biopsy for stage 2/3 acute kidney injury (AKI), and 70% recommended imaging for any stage of AKI. Thirty-five percent favored corticosteroids in AKI patients with creatinine levels 2–3-fold above baseline. For myositis, 58% would recommend a muscle biopsy in a patient with weakness and creatine kinase levels of 5000 U/L; 47% would also opt for an endomyocardial biopsy when the troponin levels are increased. Fifty-eight percent recommended oral corticosteroids for myositis, and 37% recommended additional therapy, mainly immunoglobulins. These results show substantial differences in expert practice patterns for the management of severe liver, kidney, and muscular irAEs.
Collapse
|
15
|
Cappelli LC, Bingham CO, Forde PM, Anagnostou V, Brahmer J, Lipson EJ, Mammen J, Schollenberger M, Shah AA, Darrah E. Anti-RA33 antibodies are present in a subset of patients with immune checkpoint inhibitor-induced inflammatory arthritis. RMD Open 2022; 8:rmdopen-2022-002511. [PMID: 36096522 PMCID: PMC9472204 DOI: 10.1136/rmdopen-2022-002511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Patients with inflammatory arthritis (IA) associated with immune checkpoint inhibitor (ICI) treatment for cancer are typically seronegative for anti-cyclic citrullinated peptide (CCP) antibodies and rheumatoid factor, but little is known about the presence of other autoantibodies in this patient population. We investigated the prevalence and characteristics of anti-RA33 antibodies in patients with ICI-induced IA. METHODS Anti-RA33 ELISAs were performed on sera from four groups of patients: 79 with ICI-induced IA, 52 with rheumatoid arthritis (RA), 35 treated with ICIs without IA during follow-up and 50 healthy controls. Anti-RA33 positivity and level, clinical and demographic data were compared across groups. RESULTS Anti-RA33 antibodies were found in 9/79 (11.4%) patients with ICI-induced IA but in 0/35 patients treated with ICIs who did not develop IA (0%; p=0.04). Of the patients positive for anti-RA33, two had sera available from before ICI treatment; anti-RA33 antibodies were present in both pre-ICI treatments. In patients with RA, 7.7% were positive for anti-RA33 antibodies as were 2% of healthy controls. In ICI-induced IA, anti-RA33 antibodies were associated with anti-CCP antibodies (p=0.001). We found no statistically significant differences in other clinical characteristics in those with and without anti-RA33 antibodies. CONCLUSIONS Anti-RA33 antibodies are present in a subset of patients with ICI-induced IA, absent in other ICI-treated patients and may be a biomarker for developing IA. Additional studies evaluating serial samples before and after ICI treatment will further establish the temporal relationship of these antibodies to IA development.
Collapse
Affiliation(s)
- Laura C Cappelli
- Division of Rheumatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Clifton O Bingham
- Division of Rheumatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Patrick M Forde
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Valsamo Anagnostou
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Julie Brahmer
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Evan J Lipson
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Mammen
- Division of Endocrinology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Megan Schollenberger
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Erika Darrah
- Division of Rheumatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
16
|
Grän F, Schilling B. Kutane Nebenwirkungen unter
Immun-Checkpoint-Inhibitor-Therapie. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1794-9687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
ZusammenfassungModerne Immuntherapeutika wie Nivolumab, Pembrolizumab oder Ipilimumab, die
sogenannte Immun-Checkpoints blockieren, haben die onkologische Therapie in den
letzten Jahren revolutioniert. Mit dem neuen Wirkmechanismus der Blockade
wichtiger Kontrollpunkte im Immunsystem zeigen sich jedoch auch eine Vielzahl an
unterschiedlichen Nebenwirkungen. Diese treten nicht selten an der Haut auf. Zu
den häufigsten dermalen Reaktionen unter Immuntherapie zählen
die Vitiligo, Exantheme, blasenbildende Reaktionen oder der Lichen planus.
Ausgeprägter Juckreiz kann Patienten stark beeinträchtigen. Der
Verlauf bei auf die Haut beschränkten Nebenwirkungen ist häufig
mild und gut zu behandeln oder selbstlimitierend. Hauterscheinungen
können jedoch auch als Symptom systemischer Reaktionen auftreten. Eine
frühe Diagnosestellung, die Einleitung einer adäquaten Therapie
sowie eine interdisziplinäre Betreuung bei komplexen Erkrankungen sind
entscheidend, um dauerhafte Einschränkungen für die Patienten zu
verhindern und eine sichere Behandlung der zugrundeliegenden Tumorerkrankung
gewährleisten zu können.
Collapse
Affiliation(s)
- Franziska Grän
- Dermatologie, Universitätsklinikum Würzburg,
Würzburg, Germany
| | - Bastian Schilling
- Klinik und Poliklinik für Dermatologie, Venerologie und
Allergologie, Universitätsklinikum Würzburg, Würzburg,
Germany
| |
Collapse
|
17
|
Gómez-Puerta JA, Lobo-Prat D, Perez-García C, Ponce A, Frade-sosa B, Millán Arciniegas AM, Ojeda F, Ruiz-Esquide V, Corominas H. Clinical Patterns and Follow-Up of Inflammatory Arthritis and Other Immune-Related Adverse Events Induced by Checkpoint Inhibitors. A Multicenter Study. Front Med (Lausanne) 2022; 9:888377. [PMID: 35783644 PMCID: PMC9240301 DOI: 10.3389/fmed.2022.888377] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/12/2022] [Indexed: 01/04/2023] Open
Abstract
Objectives To describe different clinical patterns of rheumatic immune-related adverse events (irAEs) induced by immune checkpoint inhibitors (ICI) and their rheumatic and oncologic outcomes. Methods We classified clinical syndromes according to five different categories: non-inflammatory arthralgias (NIA), rheumatoid arthritis (RA)-like, psoriatic arthritis (PsA)-like, polymyalgia rheumatica (PMR)-like, and a miscellaneous group of patients with other syndromes. We conducted a baseline visit and then follow-up in order to determine their clinical pattern, treatment response, and outcome. Results We included 73 patients (64% male) with a mean age of 66.1 ± 11.6 years. Main underlying diagnosis was lung carcinoma in 29 (39%) patients, melanoma in 20 (27%), and renal-urothelial cancer in 11 (15%). Main ICI included Pembrolizumab in 24 (32%), Nivolumab 17 (23%), and Atezolizumab 7 (9 %). Seventeen out of seventy-three patients had an underlying rheumatic disease before ICI treatment. Fourteen patients developed other irAEs before or simultaneously with rheumatic syndromes. Main rheumatic irAEs included: RA-like in 31 (42.4%), NIA in 19 (26.0%), PMR-like in 10 (13.7%), and PsA-like in 5 (6.8%), among others. Median time from ICI to irAEs was 5 months (IQR 3–9). Those patients who received combined therapy, had a trend for an earlier presentation than those who received monotherapy (4.3 months IQR 1.85–17 vs. 6 months IQR 3–9.25, p = NS). Mean follow-up time was 14.0 ± 10.8 (SD, months). At the last visit, 47 % were taking glucocorticoids and 11% DMARD therapy. At the last visit, 13 (17.8%) patients remained with persistent arthritis, 19 (26%) had intermittent flares, and 39 (53.4%) had a self-limited pattern. Only in 15.1% of patients ICI therapy was discontinued. Conclusions We described different patterns according to treatment and irAEs. Combined ICI therapy had an earlier onset of symptoms. Patients who presented as RA-like, had a higher risk of persistent arthritis. After a mean follow-up of more than 1 year, one-fifth of the patients remained with persistent arthritis and 11% required DMARD therapy.
Collapse
Affiliation(s)
- José A. Gómez-Puerta
- Rheumatology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Universitat de Barcelona, Barcelona, Spain
- *Correspondence: José A. Gómez-Puerta
| | - David Lobo-Prat
- Rheumatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Andrés Ponce
- Rheumatology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Beatriz Frade-sosa
- Rheumatology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Fabiola Ojeda
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
| | - Virginia Ruiz-Esquide
- Rheumatology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Hector Corominas
- Rheumatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| |
Collapse
|
18
|
Lauwyck J, Schreuer M, Meric de Bellefon L, Van Erps J, Neyns B, Aspeslagh S. Severe treatment-induced inflammatory polyarthritis in advanced melanoma patients: 2 case reports. Melanoma Res 2022; 32:200-204. [PMID: 35377860 DOI: 10.1097/cmr.0000000000000814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Immune checkpoint inhibitors (ICI) and targeted therapies form the therapeutic mainstay for v-Raf murine sarcoma viral oncogene homolog B V600-mutated metastatic melanoma. Both treatment regimens can cause inflammatory arthritis. The reported incidence of treatment-induced inflammatory arthritis is low, though presumably underestimated due to lack of awareness, clear definitions and uniform grading systems. Nevertheless, recognition is important as inflammatory arthritis can become chronic and thus affect the quality of life beyond treatment. In this short communication, we present two patients with metastatic melanoma treated with ICI and targeted therapies who develop severe polyarthritis. Based on their clinical discourse we describe standard inflammatory arthritis treatment modalities and more advanced immunomodulatory treatment options with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic DMARDs (bDMARDs). Long-term immunosuppressive treatment with glucocorticoids or DMARDs in this setting raises concerns about antitumour response and potential carcinogenic risk. Current literature on this topic is scarce, heterogeneous and retrospective. Prospective analysis of cancer patients treated with DMARDs is needed to clearly address these concerns.
Collapse
Affiliation(s)
- Justine Lauwyck
- Department of Medical Oncology, Universitair Ziekenhuis (UZ) Brussel, Laarbeeklaan, Brussel
| | - Max Schreuer
- Department of Medical Oncology, Algemeen Stedelijk Ziekenhuis (ASZ) Aalst, Merestraat, Aalst
| | - Laurent Meric de Bellefon
- Department of Rheumatology, Universitair Medisch Centrum (UMC) Sint-Pieter, Hoogstraat, Brussel, Belgium
| | - Joanna Van Erps
- Department of Medical Oncology, Algemeen Stedelijk Ziekenhuis (ASZ) Aalst, Merestraat, Aalst
| | - Bart Neyns
- Department of Medical Oncology, Universitair Ziekenhuis (UZ) Brussel, Laarbeeklaan, Brussel
| | - Sandrine Aspeslagh
- Department of Medical Oncology, Universitair Ziekenhuis (UZ) Brussel, Laarbeeklaan, Brussel
| |
Collapse
|
19
|
Araújo FC, Afonso PD. Sacroiliitis as an immune-related adverse event of pembrolizumb treatment for melanoma. Scand J Rheumatol 2022; 51:342-343. [PMID: 35383526 DOI: 10.1080/03009742.2022.2053301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- F C Araújo
- Rheumatology and Osteoporosis Unit, Hospital de Sant'Ana - SCML, Parede, Portugal
| | - P D Afonso
- Radiology Department, Hospital da Luz Lisboa, Lisboa, Portugal.,Radiology Department, Hospital Particular da Madeira, Funchal, Portugal
| |
Collapse
|
20
|
Small vessel vasculitis and dry gangrene secondary to combined CTLA-4 and PD-1 blockade in malignant mesothelioma. BMC Rheumatol 2022; 6:10. [PMID: 35130961 PMCID: PMC8821830 DOI: 10.1186/s41927-021-00238-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/03/2021] [Indexed: 11/14/2022] Open
Abstract
Background Malignant pleural mesothelioma (MPM) is a rare and aggressive tumour with an overall poor prognosis. In October 2020, first line treatment with the PD-1 antagonist nivolumab and the CTLA-4 antagonist ipilimumab for unresectable disease was FDA approved—the first approved treatment regime since 2004. Interim analyses from the phase 3 CHECKMATE-743 study shows improvements in overall survival. Skin-related toxicities are the most commonly reported any-grade treatment-related adverse event from combined nivolumab and ipilimumab therapy. Case presentation Here we report a case of a 35-year-old white male who developed digital ischaemia secondary to small vessel vasculitis after receiving PD-1 and CTLA-4 blockade therapy for MPM. His progressive ischaemia became gangrenous, and he required multi-speciality input and treatment with prednisolone, prostacyclin, mycophenolate mofetil and hydroxychloroquine. Conclusions Our case highlights the importance of early detection, intervention, and a multispecialty approach to managing such complications in order to minimise the associated morbidity and mortality.
Collapse
|
21
|
Cretu I, Cretu B, Cirstoiu C, Cursaru A, Milicescu M, Bojinca M, Ionescu R. Rheumatological Adverse Events Following Immunotherapy for Cancer. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:94. [PMID: 35056402 PMCID: PMC8778975 DOI: 10.3390/medicina58010094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/02/2022] [Accepted: 01/06/2022] [Indexed: 06/14/2023]
Abstract
Background and Objectives: The occurrence of rheumatological side effects in a patient after receiving immunotherapy for cancer is becoming increasingly common. Oncologists often fail to diagnose and refer affected patients to rheumatologists. This paper presents the various rheumatological adverse events that occur after immunotherapy in patients as well as their treatment and evolution. Materials and Methods: A total of 36 patients were monitored between November 2018 and March 2020. The oncologist monitoring the immunotherapy-treated patients identified the occurrence of musculoskeletal side effects. The grading of toxicities was performed by both the oncologist and the rheumatologist using common terminology criteria for adverse events (CTCAE). Rheumatological treatment was administered, and for some patients, immunotherapy was discontinued. Results: The clinical presentations of the patients varied. Mild side effects (grade 1-2) were reported in a higher proportion than severe side effects (grade 3-5). Therefore, thirty-one patients had mild-to-moderate side effects, and five patients had severe side effects. Adverse reactions occurred, on average, 10 weeks after the initiation of immunotherapy; this indicated that the severity of the toxicity was dose dependent. Patients were treated with NSAIDs or prednisone, depending on the severity of the side effects, and for patients with severe manifestations, immunotherapy was discontinued. The remission of rheumatic manifestations varied depending on the grade of the manifestations. Conclusions: The clinical, biological, and ultrasound presentations of the patients with adverse events followed by cancer treatments differed from classic rheumatological manifestations. Thorough examinations of these patients by both oncologists and rheumatologists are needed in order to correctly diagnose and treat rheumatological adverse events. Multiple studies that include a larger number of participants are needed in order to better understand the pathogenesis and clinical evolution of these patients under different treatment conditions.
Collapse
Affiliation(s)
- Ioana Cretu
- Department Internal Medicine & Rheumatology, Carol Davila University of Medicine & Pharmacy, Dr Ion Cantacuzino Hospital, 917151 Bucharest, Romania; (I.C.); (M.M.); (M.B.)
| | - Bogdan Cretu
- Department Orthopaedics & Traumatology, Carol Davila University of Medicine & Pharmacy, University Emergency Hospital, 050098 Bucharest, Romania; (C.C.); (A.C.)
| | - Catalin Cirstoiu
- Department Orthopaedics & Traumatology, Carol Davila University of Medicine & Pharmacy, University Emergency Hospital, 050098 Bucharest, Romania; (C.C.); (A.C.)
| | - Adrian Cursaru
- Department Orthopaedics & Traumatology, Carol Davila University of Medicine & Pharmacy, University Emergency Hospital, 050098 Bucharest, Romania; (C.C.); (A.C.)
| | - Mihaela Milicescu
- Department Internal Medicine & Rheumatology, Carol Davila University of Medicine & Pharmacy, Dr Ion Cantacuzino Hospital, 917151 Bucharest, Romania; (I.C.); (M.M.); (M.B.)
| | - Mihai Bojinca
- Department Internal Medicine & Rheumatology, Carol Davila University of Medicine & Pharmacy, Dr Ion Cantacuzino Hospital, 917151 Bucharest, Romania; (I.C.); (M.M.); (M.B.)
| | - Ruxandra Ionescu
- Department Internal Medicine & Rheumatology, Carol Davila University of Medicine & Pharmacy, Sf Maria Clinical Hospital, 011172 Bucharest, Romania;
| |
Collapse
|
22
|
Shen P, Deng X, Hu Z, Chen Z, Huang Y, Wang K, Qin K, Huang Y, Ba X, Yan J, Han L, Tu S. Rheumatic Manifestations and Diseases From Immune Checkpoint Inhibitors in Cancer Immunotherapy. Front Med (Lausanne) 2021; 8:762247. [PMID: 34805229 PMCID: PMC8599930 DOI: 10.3389/fmed.2021.762247] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/13/2021] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs), which can enhance antitumor immunity and inhibit cancer growth, have revolutionized the treatment of multiple cancers and dramatically decreased mortality. However, treatment with ICIs is directly associated with immune-related adverse events (irAEs) because of inflammation in off-target organs and autoimmunity resulting from non-specific immune activation. These irAEs can cause rheumatic diseases and manifestations such as inflammatory arthritis, polymyalgia rheumatica, myositis, vasculitis, Sicca and Sjogen's syndrome, and systemic lupus erythematosus. Early diagnosis and treatment of these adverse events will improve outcomes and quality of life for cancer patients. The treatment of rheumatic diseases induced by ICIs requires multidisciplinary cooperation among physicians. Furthermore, the underlying mechanisms are not fully understood and it is difficult to predict and evaluate these side effects precisely. In this review, we summarize available studies and findings about rheumatic irAEs, focusing mainly on the clinical manifestations, epidemiology, possible mechanisms, and guiding principles for treating these irAEs.
Collapse
Affiliation(s)
- Pan Shen
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xuan Deng
- Department of Nephrology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhishuo Hu
- Department of Emergency, Wuhan No.1 Hospital, Wuhan, China
| | - Zhe Chen
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yao Huang
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ke Wang
- Department of Integrated Traditional Chinese and Western Medicine, The Central Hospital of Wuhan, Wuhan, China
| | - Kai Qin
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ying Huang
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xin Ba
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jiahui Yan
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Liang Han
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Shenghao Tu
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
23
|
Boppana SH, Dulla NR, Beutler BD, Gullapalli N, Kaur R. Drug-Associated Eosinophilic Fasciitis: A Case of Eosinophilic Fasciitis Secondary to Cemiplimab Therapy. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932888. [PMID: 34403405 PMCID: PMC8380854 DOI: 10.12659/ajcr.932888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/07/2021] [Accepted: 07/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Eosinophilic fasciitis, also known as Shulman syndrome, is a rare inflammatory condition characterized by diffuse erythema and progressive collagenous thickening of the subcutaneous fascia. The underlying cause remains to be definitively established; however, several drugs have been linked to this uncommon clinical entity. We present a rare case of eosinophilic fasciitis secondary to immune checkpoint inhibitor therapy. CASE REPORT A 72-year-old woman with metastatic cutaneous squamous cell carcinoma presented to the rheumatology clinic for evaluation of joint pain that developed 3 weeks after beginning treatment with cemiplimab. The correlation of clinical history and physical examination was most consistent with osteoarthritis. Symptoms improved after a short course of low-dose prednisone. The patient continued cemiplimab therapy for approximately 1 year and was subsequently transitioned to carboplatin and radiation therapy. However, relapse occurred shortly thereafter, and cemiplimab was restarted. Two weeks later, the patient developed severe joint pain, morning stiffness, and extensive cutaneous discoloration and induration. A skin biopsy was performed. Microscopic examination of a tissue sample showed a mononuclear infiltrate with plasma cells and eosinophils. A diagnosis of eosinophilic fasciitis was established. Cemiplimab was held and the patient was treated with hydroxychloroquine, prednisone, and sulfasalazine. Symptoms improved within 1 week. CONCLUSIONS Eosinophilic fasciitis is a rare but important adverse effect of immune checkpoint inhibitors. Individuals receiving immunotherapy should be monitored closely for symptoms of eosinophilic fasciitis, as prompt treatment is essential to prevent long-term complications.
Collapse
Affiliation(s)
- Sri Harsha Boppana
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Nageswara Rao Dulla
- Department of Internal Medicine, Mythri Multispecialty Hospital, Guntur, India
| | - Bryce D. Beutler
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Nageshwara Gullapalli
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Ratinder Kaur
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
- Department of Rheumatology, Arthritis Consultants, Reno, NV, USA
| |
Collapse
|
24
|
Harris JA, Huang K, Miloslavsky E, Hanna GJ. Sicca syndrome associated with immune checkpoint inhibitor therapy. Oral Dis 2021; 28:2083-2092. [PMID: 34379884 DOI: 10.1111/odi.14000] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/07/2021] [Accepted: 08/03/2021] [Indexed: 12/17/2022]
Abstract
Cancer immunotherapy, which seeks to stimulate a patient's own immune system to combat cancer, is quickly becoming a central pillar of cancer therapeutics and has resulted in the development of many novel anticancer therapies. One subtype of cancer immunotherapy, immune checkpoint inhibitors (ICIs), has revolutionized cancer treatment and changed the standard of care for multiple indications. However, the advent of ICIs has produced a wide variety of inflammatory side effects termed immune-related adverse events (IRAEs), including ICI-induced Sicca syndrome. This article outlines the clinical features of ICI-induced Sicca syndrome and assesses its reported incidence in clinical trials, case series, and case reports across numerous cancers and treatment modalities. Presentations of ICI-induced Sicca syndrome in patients with pre-existing Sjӧgren's disease and with extra-glandular manifestations will also be explored. The pathophysiological mechanisms underlying IRAEs, including ICI-induced Sicca syndrome, will be evaluated through an examination of existing literature. Finally, the various treatment and management strategies as well as aims for future work will be discussed and reviewed.
Collapse
Affiliation(s)
- Jack A Harris
- Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Kevin Huang
- Harvard Medical School, Boston, Massachusetts, USA
| | - Eli Miloslavsky
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Glenn J Hanna
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
25
|
Affiliation(s)
| | - Michel G Khouri
- Duke University, Division of Cardiology, Durham, North Carolina
| | - Sophia C Weinmann
- Duke University, Division of Rheumatology and Immunology, Durham, North Carolina
| |
Collapse
|
26
|
Wojtukiewicz MZ, Rek MM, Karpowicz K, Górska M, Polityńska B, Wojtukiewicz AM, Moniuszko M, Radziwon P, Tucker SC, Honn KV. Inhibitors of immune checkpoints-PD-1, PD-L1, CTLA-4-new opportunities for cancer patients and a new challenge for internists and general practitioners. Cancer Metastasis Rev 2021; 40:949-982. [PMID: 34236546 PMCID: PMC8556173 DOI: 10.1007/s10555-021-09976-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/07/2021] [Indexed: 12/11/2022]
Abstract
The treatment of cancer patients with immune checkpoint inhibitors (ICI) (anti-CTLA-4, anti-PD-1, anti-PD-L1, combined therapy anti-PD-1/PD-L1 with anti-CTLA-4) has without doubt been a significant breakthrough in the field of oncology in recent years and constitutes a major step forward as a novel type of immunotherapy in the treatment of cancer. ICIs have contributed to a significant improvement in the outcome of treatment and prognosis of patients with different types of malignancy. With the expansion of the use of ICIs, it is expected that caregivers will face new challenges, namely, they will have to manage the adverse side effects associated with the use of these drugs. New treatment options pose new challenges not only for oncologists but also for specialists in other clinical fields, including general practitioners (GPs). They also endorse the need for taking a holistic approach to the patient, which is a principle widely recognized in oncology and especially relevant in the case of the expanding use of ICIs, which may give rise to a wide variety of organ complications resulting from treatment. Knowledge and awareness of the spectrum of immune-related adverse events (irAEs) will allow doctors to qualify patients for treatment more appropriately, prevent complications, correctly recognize, and ultimately treat them. Additionally, patients with more non-specific symptoms would be expected, in the first instance, to consult their general practitioners, as complications may appear even after the termination of treatment and do not always proceed in line with disease progression. Dealing with any iatrogenic complications, will not only be the remit of oncologists but because of the likelihood that specific organs may be affected, is likely to extend also to specialists in various fields of internal medicine. These specialists, e.g., endocrinologists, dermatologists, pulmonologists, and gastroenterologists, are likely to receive referrals for patients suffering from specific types of adverse events or will be asked to provide care in cases requiring hospitalization of patients with complications in their field of expertise. In view of these considerations, we believe that there is an urgent need for multidisciplinary teamwork in the treatment of cancer patients undergoing immunotherapy and suffering the consequent adverse reactions to treatment.
Collapse
Affiliation(s)
- Marek Z Wojtukiewicz
- Department of Oncology, Medical University of Bialystok, Bialystok, Poland. .,Department of Clinical Oncology, Comprehensive Cancer Center, Białystok, Poland.
| | - Magdalena M Rek
- Department of Oncology, Medical University of Bialystok, Bialystok, Poland.,Department of Clinical Oncology, Comprehensive Cancer Center, Białystok, Poland
| | - Kamil Karpowicz
- Department of Clinical Oncology, Comprehensive Cancer Center, Białystok, Poland
| | - Maria Górska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Barbara Polityńska
- Department of Philosophy and Human Psychology, Medical University of Białystok, Białystok, Poland.,Robinson College, Cambridge University, Cambridge, UK
| | - Anna M Wojtukiewicz
- Department of Philosophy and Human Psychology, Medical University of Białystok, Białystok, Poland
| | - Marcin Moniuszko
- Department of Allergology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland.,Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Radziwon
- Regional Centre for Transfusion Medicine, Bialystok, Poland.,Department of Hematology, Medical University of Bialystok, Bialystok, Poland
| | - Stephanie C Tucker
- Bioactive Lipids Research Program, Department of Pathology-School of Medicine, Detroit, MI, USA.,Department of Oncology, Karmanos Cancer Institute, Detroit, MI, USA
| | - Kenneth V Honn
- Bioactive Lipids Research Program, Department of Pathology-School of Medicine, Detroit, MI, USA.,Department of Chemistry, Wayne State University, Detroit, MI, USA.,Department of Oncology, Wayne State University, Detroit, MI, USA
| |
Collapse
|
27
|
Abdelrahim M, Mamlouk O, Lin H, Lin J, Page V, Abdel-Wahab N, Swan J, Selamet U, Yee C, Diab A, Suki W, Abudayyeh A. Incidence, predictors, and survival impact of acute kidney injury in patients with melanoma treated with immune checkpoint inhibitors: a 10-year single-institution analysis. Oncoimmunology 2021; 10:1927313. [PMID: 34104543 PMCID: PMC8158025 DOI: 10.1080/2162402x.2021.1927313] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The incidence of renal immune-related adverse events (irAEs) is reported to be 3.8%, with varied definitions of acute kidney injury (AKI). This study reports a 10-year experience at MD Anderson Cancer Center of patients diagnosed with melanoma and treated with immune checkpoint inhibitors (ICIs) and evaluated the incidence of AKI, associated factors, and its association with overall survival. Methods: A retrospective chart review (2010–2019) of all patients with melanoma treated with ipilimumab, nivolumab, pembrolizumab, or atezolizumab was performed. All available serum creatinine data were extracted and used to calculate the estimated GFR (eGFR) using the CKD Epi equation, and to diagnose AKI using the two KDIGO (Kidney Disease: Improving Global Outcomes) criteria for defining stage I AKI in 1664 unique patients. Cumulative incidence rates of AKI after initiation of ICIs were calculated in the presence of death as a competing risk. The effects of covariates on the cumulative incidence function of AKI were evaluated in a univariant and multivariable analysis. Overall survival was estimated by Kaplan–Meier method in accordance to the occurrence of AKI. Results: The incidence of AKI by definitions 1a and 1b were 3.49% and 3.33%, respectively. After adjudication, AKI attributable to ICI was 58% and 65% of the overall incidence of AKI in each definition respectively. Increasing age was associated with decreased risk of AKI. Asian race was associated with a higher risk of AKI. Comorbidities were not associated with increased risk of AKI while use of proton pump inhibitors (PPI), ipilimumab or ICI combinations were significantly associated with AKI. AKI was not significantly associated with overall survival. Immune-related adverse events (irAEs) occurred in 30% of patients with AKI but their incidence was not different in patients with AKI attributable to ICI versus other AKI. Conclusions: In a large population of patients with melanoma treated with ICIs, an accurate documentation of AKI in setting of ICI use and predictors associated is presented. AKI following ICI use is infrequent, not associated with mortality, and associated with the use of ipilimumab, ICI combinations and PPIs.
Collapse
Affiliation(s)
- Maen Abdelrahim
- Institute of Academic Medicine and Weill Cornell Medical College, Houston Methodist Cancer Center, Houston, Texas, USA
| | - Omar Mamlouk
- Section of Nephrology, Division of Internal Medicine, Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jamie Lin
- Section of Nephrology, Division of Internal Medicine, Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Valda Page
- Section of Nephrology, Division of Internal Medicine, Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Noha Abdel-Wahab
- Rheumatology and Rehabilitation Department, Assiut University Hospitals, Faculty of Medicine, Assiut, Egypt.,Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joshua Swan
- Department of System Pharmacy, Houston Methodist, Houston, Texas, USA
| | - Umut Selamet
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Cassian Yee
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wadi Suki
- Department of Medicine, Nephrology, Houston Methodist Hospital, Houston, Texas, USA
| | - Ala Abudayyeh
- Section of Nephrology, Division of Internal Medicine, Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
28
|
George AS, Fernandez CJ, Eapen D, Pappachan JM. Organ-specific Adverse Events of Immune Checkpoint Inhibitor Therapy, with Special Reference to Endocrinopathies. TOUCHREVIEWS IN ENDOCRINOLOGY 2021; 17:21-32. [PMID: 35118443 PMCID: PMC8320015 DOI: 10.17925/ee.2021.17.1.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/09/2021] [Indexed: 02/05/2023]
Abstract
Immune checkpoint inhibitors are potent and promising immunotherapeutic agents that are increasingly used for the management of various types of advanced cancers. The widespread approval of this group of drugs simultaneously revealed immune-related adverse events as unique side-effects. Endocrinopathies are one of the most common immune-related adverse events. The precise pathogenic mechanisms for these endocrinopathies are still unclear. Though few of the endocrinopathies are reversible, calling for only symptom control, most are irreversible, requiring multiple long-term hormone replacement therapies. However, in contrast to other organ-specific immune-related adverse events, patients with endocrinopathies can continue their immune checkpoint therapy, provided the hormone replacement therapy is adequate and the symptoms are controlled. Though patients who have developed immune-related adverse events demonstrate superior antitumor activity and overall survival, due to the high morbidity associated with the immune-related adverse events, researchers are trying to uncouple the antitumour activity associated with immune checkpoint inhibitor therapy from the immune-related adverse events, to preserve antitumour activity without adverse events.
Collapse
Affiliation(s)
- Annu Susan George
- Department of Medical Oncology, Lakeshore Hospital, Cochin, Kerala, India
| | - Cornelius J Fernandez
- Department of Endocrinology, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - Dilip Eapen
- Department of Endocrinology, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - Joseph M Pappachan
- Department of Endocrinology & Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Manchester Metropolitan University, Manchester, UK
- The University of Manchester, Manchester, UK
| |
Collapse
|
29
|
Kim ST, Pundole X, Dadu R, Lambotte O, Ramos-Casals M, Suarez-Almazor ME. Use of immune checkpoint inhibitors in cancer patients with pre-existing sarcoidosis. Immunotherapy 2021; 13:465-475. [PMID: 33641345 DOI: 10.2217/imt-2020-0272] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Aim: To evaluate adverse events in cancer patients with pre-existing sarcoidosis receiving immune checkpoint inhibitors (ICIs). Patients & methods: We retrospectively reviewed cancer patients with sarcoidosis who underwent treatment with ICI to determine frequency of sarcoidosis flares. Results: 32 patients with sarcoidosis received ICIs The median time to ICI initiation was 7 years (range: 1 month to 51 years). One patient (3%) with a 20-year remote history of sarcoidosis developed a clinically symptomatic exacerbation after three doses of atezolizumab, with hilar lymphadenopathy, subcutaneous nodules, arthritis and uveitis. Atezolizumab was discontinued and prednisone initiated. She had a fluctuating course with two additional flares. Conclusion: Frequency of flares in patients with a remote history of sarcoidosis who receive ICIs is low.
Collapse
Affiliation(s)
- Sang T Kim
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xerxes Pundole
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ramona Dadu
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Olivier Lambotte
- AP-HP. Université Paris-Saclay, Hôpital Bicêtre Department of Internal Medicine & Clinical Immunology, Le Kremlin Bicêtre, France.,Université Paris-Saclay; INSERM; CEA, Centre Immunology of Viral Infections & Autoimmune Diseases, IDMIT Department, IBFJ, Le Kremlin-Bicêtre, France
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.,Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Maria E Suarez-Almazor
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| |
Collapse
|
30
|
Karwacka I, Obołończyk Ł, Kaniuka-Jakubowska S, Sworczak K. The Role of Immunotherapy in the Treatment of Adrenocortical Carcinoma. Biomedicines 2021; 9:biomedicines9020098. [PMID: 33498467 PMCID: PMC7909536 DOI: 10.3390/biomedicines9020098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/30/2020] [Accepted: 01/18/2021] [Indexed: 01/20/2023] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare epithelial neoplasm, with a high tendency for local invasion and distant metastases, with limited treatment options. Surgical treatment is the method of choice. For decades, the mainstay of pharmacological treatment has been the adrenolytic drug mitotane, in combination with chemotherapy. Immunotherapy is the latest revolution in cancer therapy, however preliminary data with single immune checkpoint inhibitors showed a modest activity in ACC patients. The anti-neoplastic activity of immune checkpoint inhibitors such as anti-cytotoxic-T-lymphocyte-associated-antigen 4 (anti-CTLA-4), anti-programmed death-1 (anti-PD-1), and anti-PD-ligand-1 (PD-L1) antibodies in different solid tumors has aroused interest to explore the potential therapeutic effect in ACC as well. Multiple ongoing clinical trials are currently evaluating the role of immune checkpoint inhibitors in ACC (pembrolizumab, combination pembrolizumab and relacorilant, nivolumab, combination nivolumab and ipilimumab). The primary and acquired resistance to immunotherapy continue to counter treatment efficacy. Therefore, attempts are made to combine therapy: anti-PD-1 antibody and anti-CTLA-4 antibody, anti-PD-1 antibody and antagonist of the glucocorticoid receptor. The inhibitors of immune checkpoints would benefit patients with antitumor immunity activated by radiotherapy. Immunotherapy is well tolerated by patients; the most frequently observed side effects are mild. The most common adverse effects of immunotherapy are skin and gastrointestinal disorders. The most common endocrinopathy during anti-CTLA treatment is pituitary inflammation and thyroid disorders.
Collapse
|
31
|
George AS, Fernandez CJ, Eapen D, Pappachan JM. Organ-specific Adverse Events of Immune Checkpoint Inhibitor Therapy, with Special Reference to Endocrinopathies. EUROPEAN ENDOCRINOLOGY 2021. [DOI: 10.17925/ee.2021.1.1.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
32
|
Salamaliki C, Solomou EE, Liossis SNC. Immune Checkpoint Inhibitor-Associated Scleroderma-Like Syndrome: A Report of a Pembrolizumab-Induced "Eosinophilic Fasciitis-Like" Case and a Review of the Literature. Rheumatol Ther 2020; 7:1045-1052. [PMID: 33067734 PMCID: PMC7695772 DOI: 10.1007/s40744-020-00246-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/08/2020] [Indexed: 12/20/2022] Open
Abstract
Immune checkpoint inhibitors are a promising new therapeutic strategy in oncology that aims to eliminate cancer cells by enhancing patients' immune response against tumor antigens. Despite their beneficial effects, immune checkpoint inhibitors are also responsible for a plethora of autoimmune manifestations, known as immune-related adverse events. We present a case of eosinophilic fasciitis-like disorder in an 81-year-old patient treated with the programmed death cell protein 1 inhibitor pembrolizumab for non-small-cell lung cancer. The patient developed characteristic indurated skin lesions in his limbs after 1½ years of treatment with pembrolizumab and a typical “groove sign.” Raynaud’s syndrome was absent. A full-thickness biopsy confirmed the clinical diagnosis of an “EF-like” condition. Neither peripheral eosinophilia nor eosinophilic infiltrates in the skin biopsy were found. His symptoms improved after a 2.5-month CPI discontinuation and treatment with 16 mg of methylprednisolone slowly tapered to a dose of 4 mg. Eosinophilic fasciitis is a rare immune-related adverse event of CPI treatment; our literature search identified only 12 cases that fulfill the criteria of EF in patients receiving CPIs.
Collapse
Affiliation(s)
- Christina Salamaliki
- Division of Rheumatology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Elena E Solomou
- Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Stamatis-Nick C Liossis
- Division of Rheumatology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece.
| |
Collapse
|
33
|
Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of immune-mediated cardiovascular, rheumatic, and renal toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6159-6173. [PMID: 32856212 DOI: 10.1007/s00520-020-05710-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as the newest pillar of cancer treatment. Immune-mediated toxicities, stemming from increased activity within the T cell lineage, range from asymptomatic or mild complications to those that are fulminant and potentially fatal. Although they are of variable occurrence, cardiovascular, rheumatic, and renal immune-mediated toxicities are among the most serious of these adverse events. We present MASCC recommendations with respect to the workup and management of cardiovascular, rheumatic, and renal immune-mediated toxicities with a focus on presentations that require treatment with immunomodulating agents.
Collapse
|
34
|
|
35
|
Immune Checkpoint Inhibition-Does It Cause Rheumatic Diseases? Mechanisms of Cancer-Associated Loss of Tolerance and Pathogenesis of Autoimmunity. Rheum Dis Clin North Am 2020; 46:587-603. [PMID: 32631606 DOI: 10.1016/j.rdc.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mechanisms of immune checkpoints and their role in autoimmunity are discussed in the context of immune checkpoint inhibitor (ICI) therapy for cancer. The updated clinical spectrum of immune-related adverse events (irAEs), with an in-depth discussion of rheumatic irAEs, is presented. The relationship between ICI-induced loss of self-tolerance in cancer and the implications for understanding of irAEs, rheumatic irAEs in particular, is overviewed.
Collapse
|
36
|
von Itzstein MS, Khan S, Gerber DE. Investigational Biomarkers for Checkpoint Inhibitor Immune-Related Adverse Event Prediction and Diagnosis. Clin Chem 2020; 66:779-793. [PMID: 32363387 PMCID: PMC7259479 DOI: 10.1093/clinchem/hvaa081] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 03/13/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of multiple cancers. However, these promising therapies may also cause immune-related adverse events (irAEs) in a substantial proportion of patients. These autoimmune phenomena may affect almost any organ system and may occur at almost any point in therapy. In some instances, these toxicities are life-threatening and potentially permanent. Diverse clinical presentation and unpredictable timing further complicate their anticipation and diagnosis. CONTENT To improve patient safety and selection for ICI use, biomarkers for irAE diagnosis and prediction are under development. Clinicians may use traditional laboratory markers such as routine chemistries, creatinine clearance, thyroid function tests, and serum cortisol/adrenocorticotrophic hormone to monitor for specific irAEs, but noted aberrations may not necessarily represent an immune-mediated etiology. Novel biomarkers have the potential to be more specific to assist in the diagnosis of irAEs. The prediction of irAEs is more challenging. Apart from a history of autoimmune disease, no other clinical parameters are routinely used to project risk. Biomarker candidates under investigation for irAE diagnosis and prediction include blood cell analysis, chemokines/cytokines, autoantibodies, and genetic predisposition, such as human leukocyte antigen haplotype. Among other emerging candidates are immune-cell subsets, T-cell repertoire, fecal microbiome, tumor genomics, and radiomic characterization. SUMMARY Several conventional laboratory indexes of end-organ dysfunction are currently in routine clinical use for irAE monitoring and diagnosis. Novel biomarkers for the prediction and diagnosis of these irAEs, which primarily characterize patient immune function, represent an area of active investigation.
Collapse
Affiliation(s)
- Mitchell S von Itzstein
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shaheen Khan
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX
| | - David E Gerber
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
37
|
Immune Checkpoints Contribute Corneal Immune Privilege: Implications for Dry Eye Associated with Checkpoint Inhibitors. Int J Mol Sci 2020; 21:ijms21113962. [PMID: 32486493 PMCID: PMC7312178 DOI: 10.3390/ijms21113962] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/30/2020] [Accepted: 05/30/2020] [Indexed: 12/22/2022] Open
Abstract
The eye is provided with immune protection against pathogens in a manner that greatly reduces the threat of inflammation-induced vision loss. Immune-mediated inflammation and allograft rejection are greatly reduced in the eye, a phenomenon called 'immune privilege'. Corneal tissue has inherent immune privilege properties with underlying three mechanisms: (1) anatomical, cellular, and molecular barriers in the cornea; (2) an immunosuppressive microenvironment; and (3) tolerance related to regulatory T cells and anterior chamber-associated immune deviation. This review describes the molecular mechanisms of the immunosuppressive microenvironment and regulatory T cells in the cornea that have been elucidated from animal models of ocular inflammation, especially those involving corneal transplantation, it also provides an update on immune checkpoint molecules in corneal and systemic immune regulation, and its relevance for dry eye associated with checkpoint inhibitor therapy.
Collapse
|
38
|
Rheumatic Manifestations in Patients Treated with Immune Checkpoint Inhibitors. Int J Mol Sci 2020; 21:ijms21093389. [PMID: 32403289 PMCID: PMC7247001 DOI: 10.3390/ijms21093389] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that activate the immune system, aiming at enhancing antitumor immunity. Their clinical efficacy is well-documented, but the side effects associated with their use are still under investigation. These drugs cause several immune-related adverse events (ir-AEs), some of which stand within the field of rheumatology. Herein, we present a literature review performed in an effort to evaluate all publicly available clinical data regarding rheumatic manifestations associated with ICIs. The most common musculoskeletal ir-AEs are inflammatory arthritis, polymyalgia rheumatica and myositis. Non-musculoskeletal rheumatic manifestations are less frequent, with the most prominent being sicca, vasculitides and sarcoidosis. Cases of systemic lupus erythematosus or scleroderma are extremely rare. The majority of musculoskeletal ir-AEs are of mild/moderate severity and can be managed with steroids with no need for ICI discontinuation. In severe cases, more intense immunosuppressive therapy and permanent ICI discontinuation may be employed. Oncologists should periodically screen patients receiving ICIs for new-onset inflammatory musculoskeletal complaints and seek a rheumatology consultation in cases of persisting symptoms.
Collapse
|
39
|
Checkpoint inhibitors (CPI) and autoimmune chronic inflammatory diseases (ACIDs): tolerance and loss of tolerance in the occurrence of immuno-rheumatologic manifestations. Clin Immunol 2020; 214:108395. [DOI: 10.1016/j.clim.2020.108395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/18/2020] [Accepted: 03/25/2020] [Indexed: 12/15/2022]
|
40
|
Ihle CL, Owens P. Integrating the immune microenvironment of prostate cancer induced bone disease. Mol Carcinog 2020; 59:822-829. [PMID: 32233011 DOI: 10.1002/mc.23192] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/03/2020] [Accepted: 03/17/2020] [Indexed: 12/11/2022]
Abstract
Prostate cancer (PCa) is the most frequently diagnosed cancer for men in the U.S. but does not impede patient survival until the disease is metastatic. Metastatic lesions most frequently occur in the bone, which exhibits a distinct microenvironment of immune and bone cell populations. Advances in the diagnosis and treatment of primary PCa allow for the use of tailored therapeutic approaches based on biomarkers, protein expression, and histopathology. Understanding the molecular and cellular characteristics of primary tumors has advanced therapeutic development and survival for patients with PCa. Personalized medicine has only recently emerged for the treatment of metastatic bone lesions. Tumor induced bone disease (TIBD) in patients with PCa can be classified into lytic, blastic, or mixed pathologies, with most patients exhibiting the blastic phenotype. Progress has been made in treating TIBD, but metastatic PCa has yet to be cured. Immune checkpoint inhibitors have exhibited limited responses in immunosuppressive PCa tumors, but have yet to be assessed in metastatic sites which may be susceptible to an increased inflammatory response. Recent discoveries have uncovered distinct tumor microenvironments (TMEs) of blastic and lytic bone metastases from patients with PCa, identifying actionable targets for therapeutic applications, including immune checkpoint inhibitors and targeted therapeutics. Enrichment for macrophages and T cells in patient samples suggests metastatic sites may be reappraised as immunologically targetable, despite their immunologically "cold" primary tumors. The practice of performing bone biopsies will help identify unique cellular and protein targets in the bone TME that can guide therapy decisions.
Collapse
Affiliation(s)
- Claire L Ihle
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Philip Owens
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Department of Veterans Affairs, Research Service, Eastern Colorado Health Care System, Aurora, Colorado
| |
Collapse
|