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Khalatbari H, Shulkin BL, Parisi MT. Emerging Trends in Radionuclide Imaging of Infection and Inflammation in Pediatrics: Focus on FDG PET/CT and Immune Reactivity. Semin Nucl Med 2023; 53:18-36. [PMID: 36307254 DOI: 10.1053/j.semnuclmed.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
The most common indication for 18F-FDG PET/CT is tumor imaging, which may be performed for initial diagnosis, staging, therapeutic response monitoring, surveillance, or suspected recurrence. In the routine practice of pediatric nuclear medicine, most infectious, inflammatory, and autoimmune processes that are detected on 18F-FDG PET/CT imaging - except for imaging in fever or inflammation of unknown origin - are coincidental and not the main indication for image acquisition. However, interpreting these "coincidental" findings is of utmost importance to avoid erroneously attributing these findings to a neoplastic process. We review the recent literature on fever of unknown origin as well as inflammation of unknown origin in pediatrics and then focus on the 18F FDG PET/CT imaging findings seen in two specific entities with increased immune reactivity: hemophagocytic lymphohistiocytosis syndrome and the immune-related adverse events associated with checkpoint inhibitors. We will subsequently close with two sections highlighting related topics and relevant references for further reading.
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Affiliation(s)
- Hedieh Khalatbari
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Barry L Shulkin
- Department of Diagnostic Radiology, St. Jude Children's Research Hospital, Memphis, TN.
| | - Marguerite T Parisi
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
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Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of severe gastrointestinal and hepatic toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6129-6143. [PMID: 32856210 DOI: 10.1007/s00520-020-05707-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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-related adverse events (IrAEs) affecting the gastrointestinal (GI) tract and liver are among the most frequent and most severe inflammatory toxicities from contemporary immunotherapy. Inflammation of the colon and or small intestines (entero)colitis is the single most common GI IrAE and is an important cause of delay of discontinuation of immunotherapy. The severity of these GI IrAEs can range from manageable with symptomatic treatment alone to life-threatening complications, including perforation and liver failure. The frequency and severity of GI IrAEs is dependent on the specific immunotherapy given, with cytotoxic T lymphocyte antigen (CTLA)-4 blockade more likely to induce severe GI IrAEs than blockade of either programmed cell death protein 1 (PD-1) or PD-1 ligand (PD-L1), and combination therapy showing the highest rate of GI IrAEs, particularly in the liver. To date, we have minimal prospective data on the appropriate diagnosis and management of GI IrAEs, and recommendations are based largely on retrospective data and expert opinion. Although clinical diagnoses of GI IrAEs are common, biopsy is the gold standard for diagnosis of both immunotherapy-induced enterocolitis and hepatitis and can play an important role in excluding competing, though less common, diagnoses and ensuring optimal management. GI IrAEs typically respond to high-dose corticosteroids, though a significant fraction of patients requires secondary immune suppression. For colitis, both TNF-α blockade with infliximab and integrin inhibition with vedolizumab have proved highly effective in corticosteroid-refractory cases. Detailed guidelines have been published for the management of low-grade GI IrAEs. In the setting of more severe toxicities, involvement of a GI specialist is generally recommended. The purpose of this review is to survey the available literature and provide management recommendations focused on the GI specialist.
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Thomas R, Sebastian B, George T, Majeed NF, Akinola T, Laferriere SL, Braschi-Amirfarzan M. A review of the imaging manifestations of immune check point inhibitor toxicities. Clin Imaging 2020; 64:70-79. [PMID: 32334270 DOI: 10.1016/j.clinimag.2020.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/24/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
The past decade has witnessed a paradigm shift in cancer therapy owing to the introduction of immune checkpoint inhibitors (ICIs) and it is now commonplace for radiologists to image patients on therapy with these agents. The purpose of this review is to detail the mechanism, radiological manifestations and clinical significance of ICI related toxicities, according to the organ system involved. ICI related toxicities that have known imaging manifestations include colitis, enterocolitis, pancreatitis, hepatitis, endocrine toxicities, pneumonitis, cardiovascular toxicity and musculoskeletal toxicity. These toxicities may be acute, recurrent or chronic in nature. Radiologists must be aware of the imaging features and clinical significance of these toxicities in order to effectively participate in personalized cancer therapy.
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Affiliation(s)
- Richard Thomas
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, United States of America; Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Ave, Boston 02215, MA, United States of America.
| | - Bibin Sebastian
- Department of Radiology, Government Medical College, Kozhikode 673008, Kerala, India
| | - Tom George
- Department of Radiology, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Noor Fatima Majeed
- Department of Radiology, Beth Israel Lahey Health, Lahey Health Medical Center, Tufts University School of Medicine, Burlington, MA 01805, United States of America.
| | - Temilola Akinola
- Department of Radiology, Beth Israel Lahey Health, Lahey Health Medical Center, Tufts University School of Medicine, Burlington, MA 01805, United States of America.
| | - Shawn L Laferriere
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, United States of America; Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Ave, Boston 02215, MA, United States of America; Department of Radiology, Cary Medical Center, 163 Van Buren Rd, Caribou, ME 04736, United States of America.
| | - Marta Braschi-Amirfarzan
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, United States of America; Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Ave, Boston 02215, MA, United States of America; Department of Radiology, Beth Israel Lahey Health, Lahey Health Medical Center, Tufts University School of Medicine, Burlington, MA 01805, United States of America.
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Dougan M. Gastrointestinal and Hepatic Complications of Immunotherapy: Current Management and Future Perspectives. Curr Gastroenterol Rep 2020; 22:15. [PMID: 32185493 DOI: 10.1007/s11894-020-0752-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Checkpoint inhibitor (CPI) immunotherapy has transformed the treatment of multiple cancers over the past decade, leading to durable remissions, but also to severe inflammatory toxicities. These toxicities, termed immune-related adverse events (irAEs), can affect any organ system in the body, but commonly induce inflammation in barrier organs. Gastrointestinal (GI) and hepatic irAEs are among the most frequent and most severe from contemporary immunotherapies, with inflammation in the colon and or small intestines (entero)colitis as the single most common GI irAE. The aim of this review is to describe the evidence supporting our current understanding of CPI enterocolitis and hepatitis, as well as the management of these entities. RECENT FINDINGS Although most patients who develop enterocolitis recover without long-term GI sequelae, enterocolitis is still an important reason for treatment discontinuation, which, in patients with metastatic cancer, can be a life-threatening outcome. At present, we have almost no prospective, randomized data regarding the management of CPI enterocolitis, and current management algorithms are based on expert opinion and small retrospective studies with a high likelihood of bias. Retrospective studies have defined colonic ulceration as a predictor of colitis responsiveness to corticosteroids, and have defined microscopic colitis as a subtype of CPI enterocolitis with a distinct treatment response. Corticosteroids appear to be effective for 60-70% of patients with CPI enterocolitis, with about a third of patients requiring escalation to a biologic agent such as infliximab or vedolizumab. Yet proper sequencing of these treatments to minimize risk and maximize treatment benefit has not been established, and we do not know how treatment of colitis influences cancer outcomes. CPI enterocolitis and hepatitis are important causes of treatment interruption and discontinue, and significant morbidity in patients undergoing immunotherapy. As guidelines for diagnosis and management rely heavily on expert opinion, we have an urgent need for randomized and prospective trials that use both colitis and cancer outcomes to determine optimal management strategies.
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Affiliation(s)
- Michael Dougan
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Hughes MS, Zheng H, Zubiri L, Molina GE, Chen ST, Mooradian MJ, Allen IM, Reynolds KL, Dougan M. Colitis after checkpoint blockade: A retrospective cohort study of melanoma patients requiring admission for symptom control. Cancer Med 2019; 8:4986-4999. [PMID: 31286682 PMCID: PMC6718531 DOI: 10.1002/cam4.2397] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/28/2019] [Accepted: 06/14/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (CPIs) have revolutionized oncologic therapy but can lead to immune-related adverse events (irAEs). Corticosteroids are first-line treatment with escalation to biologic immunosuppression in refractory cases. CPI-related gastroenterocolitis (GEC) affects 20%-50% of patients receiving CPIs and can carry significant morbidity and mortality. Severe CPI-related GEC is not well-described. We present the clinical characterization of all CPI-related GEC requiring admission at a single institution. METHODS Clinical, laboratory, radiographic, and endoscopic data were extracted from charts of all melanoma patients ≥18 years of age admitted to one institution for CPI-related GEC, from February 5, 2011 to December 13, 2016. Patients were followed until December 31, 2017 for further admissions. Survival, outcomes, and pharmaceutical-use analyses were performed. RESULTS Median time-to-admission from initial CPI exposure was 73.5 days. Median length of stay was 4.5 days. About 50.0% required second-line immunosuppression. Readmission for recrudescence occurred in 33.3%. Common Terminology Criteria for Adverse Events (CTCAE) grade was not significantly associated with outcomes. Hypoalbuminemia (P = 0.005), relative lymphopenia (P = 0.027), and decreased lactate dehydrogenase (P = 0.026) were associated with second-line immunosuppression. There was no difference in progression-free survival (PFS) or OS (P = 0.367, 0.400) for second-line immunosuppression. Subgroup analysis showed that early corticosteroid administration (P = 0.045) was associated with decreased PFS. CONCLUSIONS Severe CPI-related GEC typically manifests within 3 months of immunotherapy exposure. Rates of second-line immunosuppression and readmission for recrudescence were high. CTCAE grade did not capture the degree of severity in our cohort. Second-line immunosuppression was not associated with poorer oncologic outcomes; however, early corticosteroid exposure was associated with decreased PFS. Further investigation is warranted.
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Affiliation(s)
- Michael S. Hughes
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Hui Zheng
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Leyre Zubiri
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Gabriel E. Molina
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Steven T. Chen
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
- Department of DermatologyMassachusetts General HospitalBostonMassachusetts
| | - Meghan J. Mooradian
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
- Massachusetts General Hospital Cancer CenterBostonMassachusetts
| | - Ian M. Allen
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
| | - Kerry L. Reynolds
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
- Massachusetts General Hospital Cancer CenterBostonMassachusetts
| | - Michael Dougan
- Harvard Medical SchoolBostonMassachusetts
- Department of MedicineMassachusetts General HospitalBostonMassachusetts
- Division of GastroenterologyMassachusetts General HospitalBostonMassachusetts
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