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Pichon S, Aigrain P, Lacombe C, Lemarchant B, Ledoult E, Koether V, Leurs A, Zebian G, Launay D, Gachet B, Levy C. Immune checkpoint inhibitors-associated cranial nerves involvement: a systematic literature review on 136 patients. J Neurol 2024; 271:6514-6525. [PMID: 39225744 PMCID: PMC11446990 DOI: 10.1007/s00415-024-12660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 08/20/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE Describe the demographic data and clinical phenotype of cranial palsy induced by immune checkpoint inhibitors (CNP-ICI). METHODS A systematic literature review of the literature was performed in Pubmed, Web of Science, and Embase, including 68 articles and 136 patients (PROSPERO no. CRD42024517262). RESULTS Out of the 1205 articles screened, 68 articles were included after fulfilling the inclusion criteria, for a total of 136 patients. All articles were case reports and case series. In the cohort studied, 52% of patients were treated with anti PD-1/PDL-1 therapies, 14% with anti CTLA-4 therapies, and 34% with a combination of anti CTLA-4 and anti PD-1/PDL-1 therapies. The facial nerve was the most affected cranial nerve, involved in 38% of cases, followed by the optic nerve (35%), the cochleovestibular nerve (12%), and the abducens nerve (10%). The median time from the initial immune checkpoint inhibitor (ICI) injection to the onset CNP-ICI was 10 weeks (IQR 4-20). Magnetic resonance imaging demonstrated contrast enhancement or abnormal signal of the affected nerve in 43% of cases. Cerebrospinal fluid analysis indicated lymphocytic pleocytosis in 59% of cases. At the onset of immune-related adverse events, 89% of patients discontinued immunotherapy, and 92% received treatment for CNP-ICI. Treatment regimens included corticosteroids in 86% of cases, intravenous immunoglobulin in 21%, and plasma exchange in 5.1%. Among the whole population, 33% achieved recovery, 52% showed clinical improvement, 16% remained stable, and 3% experienced worsening of their condition. Rechallenge with immunotherapy was significantly associated with the emergence of new immune-related Adverse Events (irAEs). CONCLUSION ICI therapy may lead to cranial nerve involvement, particularly affecting the facial nerve, typically presenting around 10 weeks after treatment initiation. While corticosteroid therapy often resulted in patient improvement, rechallenging with ICIs were associated with new irAEs.
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Affiliation(s)
- Samuel Pichon
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France.
| | - Pauline Aigrain
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - Charlotte Lacombe
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - Bruno Lemarchant
- Département de Neurologie, CRC-SEP, Université de Lille, CHU Lille, 59000, Lille, France
| | - Emmanuel Ledoult
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
- U1286-INFINITE-Institute for Translational Research in Inflammation, INSERM, Université de Lille, CHU Lille, Lille, France
| | - Vincent Koether
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
| | - Amélie Leurs
- Département de Médecine Interne et Maladies Infectieuses, CH Dunkerque, 59240, Dunkerqu, France
| | - Ghadi Zebian
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
| | - David Launay
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes et Auto-Inflammatoires Systémiques Rares de L'Adulte du Nord, Nord-Ouest, Université de Lille, CHU Lille, Méditerranée et Guadeloupe (CeRAINOM), Pointe-à-Pitre, France
- U1286-INFINITE-Institute for Translational Research in Inflammation, INSERM, Université de Lille, CHU Lille, Lille, France
| | - Benoit Gachet
- Service de Maladies Infectieuses, CH Gustave Dron, Université de Lille, 59200, Tourcoing, France
- ULR 2694 METRICS Evaluation des Technologies de Santé et des Pratiques Médicales, CH de Tourcoing, Université de Lille, 59000, Lille, France
| | - Clémentine Levy
- Pôle de Réanimation, Université de Lille, CHU Lille, 59000, Lille, France
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L’Orphelin JM, Dollalille C, Akroun J, Alexandre J, Dompmartin A. Cardiovascular Immunotoxicity Associated with Immune Checkpoint Inhibitors in Metastatic Melanoma. Cancers (Basel) 2023; 15:cancers15072170. [PMID: 37046831 PMCID: PMC10093552 DOI: 10.3390/cancers15072170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023] Open
Abstract
Background: Checkpoint inhibitors, such as PD-1 inhibitors (nivolumab, pembrolizumab) and anti-CTLA-4 (CD152) (ipilimumab), are widely used in metastatic melanoma, and most immune-related adverse events are known. Several cardiovascular AEs (CVAEs) associated with immune checkpoint inhibitor exposure have been reported in post-marketing surveillance studies and represent major issues for patients with melanoma during and after cancer treatment. Data on CVAES induced by immune checkpoint inhibitors in melanoma, especially incidence and risk factors, are lacking. Methods: A systematic review of the literature up to 31 August 2020 was performed in Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and the ClinicalTrials.gov register according to prespecified selection criteria from inception to 7 April 2020. Statistics were performed on 3289 patients from five randomized clinical trials on melanoma. Results: Patients with melanoma treated with immune checkpoint inhibitors had a significant risk of presenting dyslipidemia (Peto OR: 4.74, 95% CI: 2.16–10.41, p < 0.01, I2 = 0%, p = 0.94). The Peto OR was numerically significant for pericarditis, myocarditis, heart failure, myocardial infarction, cerebral ischemia, high pulmonary pressure, blood high pressure, arrhythmias, endocarditis, and conduction disturbances, but the confidence interval was not significant. The risk of CVAEs was not statistically different between melanoma treated with immune checkpoint inhibitors and other tumors treated with immune checkpoint inhibitors (range of p-value from 0.13 to 0.95). No interaction between follow-up length and CVAE reporting was found. Conclusions: Our study underlines that checkpoint inhibitors used for melanoma increase CVAEs, especially dyslipidemia, which could pave the way to chronic inflammatory processes, atherosclerosis, and, finally, ischemic cardiopathy. These cardiovascular adverse events could be acute or delayed, justifying the monitoring of lipidic biology and a baseline cardiology consultation.
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Affiliation(s)
| | - Charles Dollalille
- Department of Cardiology, Caen-Normandie University Hospital, 14033 Caen CEDEX, France
| | - Julia Akroun
- Department of Dermatology, Caen-Normandie University Hospital, 14033 Caen CEDEX, France
| | - Joachim Alexandre
- Department of Cardiology, Caen-Normandie University Hospital, 14033 Caen CEDEX, France
| | - Anne Dompmartin
- Department of Dermatology, Caen-Normandie University Hospital, 14033 Caen CEDEX, France
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Boutros A, Bottini A, Rossi G, Tanda ET, Spagnolo F, Barletta G, Croce E, Fava P, Parisi A, De Rosa F, Palla M, Marconcini R, Ferrari M, Grandis M, Spallarossa P, Sarocchi M, Arboscello E, Del Mastro L, Lambertini M, Pronzato P, Genova C. Neuromuscular and cardiac adverse events associated with immune checkpoint inhibitors: pooled analysis of individual cases from multiple institutions and literature. ESMO Open 2023; 8:100791. [PMID: 36791639 PMCID: PMC9958259 DOI: 10.1016/j.esmoop.2023.100791] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have revolutionized the management of multiple tumors, due to improved efficacy, quality of life, and safety. While most immune-related adverse events (irAEs) are mild and easily managed, in rare cases such events may be life-threatening, especially those affecting the neuromuscular and cardiac system. The management of neuromuscular/cardiac irAEs is not clear due to the lack of consistent data. Therefore, we carried out a pooled analysis of collected cases from selected Italian centers and individual data from published case reports and case series, in order to improve our understanding of these irAEs. PATIENTS AND METHODS We collected retrospective data from patients treated in six Italian centers with ICIs (programmed cell death protein 1 or programmed death-ligand 1 and/or cytotoxic T-lymphocyte antigen 4 inhibitor) for any solid tumor who experienced neuromuscular and/or cardiovascular toxicity. Then, we carried out a search of case reports and series of neuromuscular/cardiac irAEs from ICIs with any solid tumor. RESULTS This analysis includes cases from Italian institutions (n = 18) and the case reports identified in our systematic literature search (n = 120), for a total of 138 patients. Among these patients, 50 (36.2%) had complete resolution of their neuromuscular/cardiac irAEs, in 21 (15.2%) cases there was a clinical improvement with mild sequelae, and 53 (38.4%) patients died as a result of the irAEs. Factors significantly associated with worse outcomes were early irAE onset, within the first two cycles of ICI (Fisher P < 0.0001), clinical manifestation of both myositis and myocarditis when compared with patients who developed only myositis or myocarditis (chi-square P = 0.0045), and the development of arrhythmia (Fisher P = 0.0070). CONCLUSIONS To the best of our knowledge, this is the largest collection of individual cases of immune-related myocarditis/myositis. Early irAE onset, concurrent development of myositis and myocarditis, as well as occurrence of arrhythmias are associated with worse outcomes and should encourage an aggressive immunomodulatory treatment.
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Affiliation(s)
- A Boutros
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy.
| | - A Bottini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy
| | - G Rossi
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - E T Tanda
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - F Spagnolo
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), Plastic Surgery Division, University of Genova, Genoa, Italy
| | - G Barletta
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - E Croce
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Fava
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Torino, Italy
| | - A Parisi
- Department of Life, Health & Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - F De Rosa
- IRCCS Istituto Romagnolo per lo Studio dei Tumori 'Dino Amadori', Meldola (FC), Italy
| | - M Palla
- Department of Skin Cancers, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - R Marconcini
- Azienda Ospedaliero Universitaria Pisana, Medical Oncology Unit, Pisa, Italy
| | - M Ferrari
- Azienda Ospedaliero Universitaria Pisana, Medical Oncology Unit, Pisa, Italy
| | - M Grandis
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Spallarossa
- Cardiovascular Disease Unit, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - M Sarocchi
- Cardiovascular Disease Unit, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - E Arboscello
- Emergency Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - L Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - M Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Pronzato
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - C Genova
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Seligman C, Chang YM, Luo J, Garden OA. Exploring the role of immune checkpoint inhibitors in the etiology of myasthenia gravis and Lambert-Eaton myasthenic syndrome: A systematic review. Front Neurol 2023; 13:1004810. [PMID: 36698907 PMCID: PMC9868566 DOI: 10.3389/fneur.2022.1004810] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Background While immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of cancer, their administration has been associated with a variety of immune-related adverse events (irAEs), including myasthenia gravis (MG), and Lambert-Eaton myasthenic syndrome (LEMS). Objective To provide a comprehensive synthesis of the evidence supporting an etiological role for ICIs in MG and LEMS in patients with no prior history of autoimmune disease. Hypothesis ICIs may trigger MG and LEMS in patients with no prior susceptibility to autoimmune disease. Methods Relevant primary research on Medline was interrogated using a series of search algorithms. Search terms were constructed based on the PICOS tool endorsed by the Cochrane Collaboration, which describes population, intervention, comparison, outcomes, and study design. Papers were screened according to inclusion and exclusion criteria. Additional papers were retrieved from the reference lists of screened papers. Each paper included in the qualitative synthesis was assigned an integrated metric of evidence (IME) value, ranging from 0 to 7, based on study design, quality of data, likelihood of a causal link between the immune checkpoint inhibitor(s) and MG/LEMS, confidence of MG/LEMS diagnosis, and the number of patients treated with an ICI prior to MG/LEMS diagnosis. Results Ninety-four papers describing at least one patient treated with ICI(s) prior to the onset of MG and/or LEMS were documented. Overall evidence for a causal link between ICI administration and MG/LEMS was low, with a median IME value of 2.88 (range 2.05-6.61). Conclusions There is a paucity of evidence in support of an etiological relationship between ICIs and MG/LEMS, due largely to the lack of mechanistic studies and/or prospective clinical trials with relevant study endpoints. The current literature is dominated by case reports and retrospective cohort studies, which inherently yield only low-level evidence, supporting the need for further work in this area. A role of ICIs in the etiology of MG/LEMS remains plausible, arguing for continued vigilance for irAEs in patients treated with these drugs. We argue that there is a need for future mechanistic, high quality, large-scale studies specifically investigating the possible etiological role of ICIs in MG/LEMS.
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Affiliation(s)
- Carly Seligman
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Yu-Mei Chang
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, United Kingdom
| | - Jie Luo
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Oliver A. Garden
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States,Dean's Office, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States,*Correspondence: Oliver A. Garden ✉
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Wang G, He X, Wang Q. Intratumoral bacteria are an important "accomplice" in tumor development and metastasis. Biochim Biophys Acta Rev Cancer 2023; 1878:188846. [PMID: 36496095 DOI: 10.1016/j.bbcan.2022.188846] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/09/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022]
Abstract
As emerging tumor components, intratumoral bacteria have been found in many solid tumors. Several studies have demonstrated that different cancer subtypes have distinct microbial compositions, and mechanistic studies have shown that intratumoral bacteria may promote cancer initiation and progression through DNA damage, epigenetic modification, inflammatory responses, modulation of host immunity and activation of oncogenes or oncogenic pathways. Moreover, intratumoral bacteria have been shown to modulate tumor metastasis and chemotherapy response. A better understanding of the tumor microenvironment and its associated microbiota will facilitate the design of new metabolically engineered species, opening up a new era of intratumoral bacteria-based cancer therapy. However, many questions remain to be resolved, such as where intratumoral bacteria originate and whether there is a direct causal relationship between intratumoral bacteria and tumor susceptibility. In addition, suitable preclinical models and more advanced detection techniques are crucial for studying the biological functions of intratumoral bacteria. In this review, we summarize the complicated role of intratumoral bacteria in the regulation of cancer development and metastasis and discuss their carcinogenic mechanisms and potential therapeutic aspects.
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Affiliation(s)
- Gang Wang
- Department of General Surgery, The First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China; Department of General Surgery, The 74th Group Army Hospital, Guangzhou 510318, China
| | - Xianli He
- Department of General Surgery, Tangdu Hospital, Air Force Military Medical University, Xi'an 710032, Shaanxi, China.
| | - Qian Wang
- Department of General Surgery, The First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China.
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Cozma A, Sporis ND, Lazar AL, Buruiana A, Ganea AM, Malinescu TV, Berechet BM, Fodor A, Sitar-Taut AV, Vlad VC, Negrean V, Orasan OH. Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: A Systematic Review. Int J Mol Sci 2022; 23:ijms231810948. [PMID: 36142866 PMCID: PMC9502843 DOI: 10.3390/ijms231810948] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are an important advancement in the field of cancer treatment, significantly improving the survival of patients with a series of advanced malignancies, like melanoma, non-small cell lung cancer (NSCLC), hepatocellular carcinoma (HCC), renal cell carcinoma (RCC), and Hodgkin lymphoma. ICIs act upon T lymphocytes and antigen-presenting cells, targeting programmed cell death protein 1 (PD1), programmed cell death protein ligand 1 (PD-L1), and cytotoxic T-lymphocyte antigen 4 (CTLA-4), breaking the immune tolerance of the T cells against malignant cells and enhancing the body's own immune response. A variety of cardiac-adverse effects are associated with ICI-based treatment, including pericarditis, arrhythmias, cardiomyopathy, and acute coronary syndrome, with myocarditis being the most studied due to its often-unexpected onset and severity. Overall, Myocarditis is rare but presents an immune-related adverse event (irAE) that has a high fatality rate. Considering the rising number of oncological patients treated with ICIs and the severity of their potential adverse effects, a good understanding and continuous investigation of cardiac irAEs is of the utmost importance. This systematic review aimed to revise recent publications (between 2016-2022) on ICI-induced cardiac toxicities and highlight the therapeutical approach and evolution in the selected cases.
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Affiliation(s)
- Angela Cozma
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Nicolae Dan Sporis
- Department of Medical Oncology, Prof. Dr. I. Chiricuta Oncology Institute, 400015 Cluj-Napoca, Romania
| | - Andrada Luciana Lazar
- Department of Dermatology, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Andrei Buruiana
- Department of Medical Oncology, Prof. Dr. I. Chiricuta Oncology Institute, 400015 Cluj-Napoca, Romania
- Correspondence:
| | - Andreea Maria Ganea
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Toma Vlad Malinescu
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Bianca Mihaela Berechet
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Adriana Fodor
- Clinical Centre of Diabetes, Nutrition and Metabolic Disease, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Adela Viviana Sitar-Taut
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Vasile Calin Vlad
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Vasile Negrean
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Olga Hilda Orasan
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Myocarditis Induced by Immunotherapy in Metastatic Melanoma—Review of Literature and Current Guidelines. J Clin Med 2022; 11:jcm11175182. [PMID: 36079112 PMCID: PMC9457343 DOI: 10.3390/jcm11175182] [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: 06/25/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Immunotherapy is a widely used treatment modality in oncology. Immune checkpoint inhibitors, as a part of immunotherapy, caused a revolution in oncology, especially in melanoma therapy, due to the significant prolongation of patients’ overall survival. These drugs act by activation of inhibited immune responses of T lymphocytes against cancer cells. The mechanism responsible for the therapy’s high efficacy is also involved in immune tolerance of the patient’s own tissues. The administration of ICI therapy to a patient can cause severe immune reactions against non-neoplastic cells. Among them, cardiotoxicity seems most important due to the high mortality rate. In this article, we present the history of a 79 year-old patient diagnosed with melanoma who died due to myocarditis induced by ICI therapy, despite the fast administration of recommended immunosuppressive therapy, as an illustration of possible adverse events of ICI. Additionally, we summarize the mechanism, risk factors, biomarkers, and clinical data from currently published guidelines and studies about ICI-related myocarditis. The fast recognition of this fatal adverse effect of therapy may accelerate the rapid introduction of treatment and improve patients’ outcomes.
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Lei Y, Zheng X, Huang Q, Li X, Qiu M, Liu M. Intrinsic Differences in Immune Checkpoint Inhibitor-Induced Myocarditis: A Retrospective Analysis of Real World Data. Front Pharmacol 2022; 13:914928. [PMID: 35865949 PMCID: PMC9294234 DOI: 10.3389/fphar.2022.914928] [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: 04/07/2022] [Accepted: 06/06/2022] [Indexed: 12/01/2022] Open
Abstract
Immune-related myocarditis is a severe and even life-threatening immune-related adverse event (irAE) which may also be underestimated due to the challenge in diagnosis. The inherent difference between individuals with immune-associated myocarditis has received little attention. Our study aimed to identify which baseline characteristics could contribute to distinguishing mild from severe ICI myocarditis. A retrospective analysis was conducted between March 2019 and June 2020 in West China Hospital, and 18 patients with immune-related myocarditis were studied. Patients were classified as having mild (n = 12) or severe myocarditis (n = 6), according to the clinical manifestations and hemodynamic complications. Factors associated with severe myocarditis were identified by comparing covariates derived from medical records in various groups. In this retrospective analysis, the median age of the 18 patients was 60 years old. Most myocarditis cases occur early and approximately after the first or second ICI infusion. The severity of myocarditis may be correlated with lactate dehydrogenase (LDH) (p = 0.04) and troponin levels (p = 0.0057). The relationship between troponin and myocarditis was further confirmed in another cohort, which included 30 patients. In addition, patients are more likely to develop multi-irAEs, and myositis was the most common second irAE. Those who experience multi-irAEs usually had significantly higher LDH (p = 0.02) and myoglobin levels (p = 0.02) than those who did not experience them. All patients were treated with steroids timely, and the mortality rate was 5.6% in our study. In this study, we explored risk factors for severe myocarditis and emphasized the importance of a multidisciplinary team in assisting diagnosis and treatment options. It is critical to initiate corticosteroid therapy, regardless of the severity of the myocarditis.
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Thakker RA, Lee MA, Albaeni A, Elbadawi A, Suthar KH, Perez C, Sonstein LK, Farr NM, Venkatesan R, Khalife W, Berbarie RF, Chatila KF. Clinical Characteristics and Outcomes in Immune Checkpoint Inhibitor Therapy-Associated Myocarditis. Cardiol Res 2021; 12:270-278. [PMID: 34691324 PMCID: PMC8510657 DOI: 10.14740/cr1319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) therapy has played an important role in the treatment of several groups of cancers. Although a life prolonging treatment, many side effects have been shown with ICI therapy. This study looked at individual level clinical characteristics and outcomes with ICI therapy in patients who developed ICI-related myocarditis. A comprehensive review of the National Library of Medicine PubMed database was performed. Inclusion criteria were all studies that were composed of case reports and case series of individual patients undergoing ICI therapy that developed myocarditis. To appreciate individual patient level data, observational studies, clinical trials, systematic reviews, and meta-analyses were excluded. Our search yielded 333 results with 71 cases reviewed of ICI therapy-related myocarditis. The findings included an average age of 68 years, higher incidence in men, and pretreatment cardiac history of hypertension. Melanoma was the most prevalent malignancy with nivolumab being the most used ICI therapy. Heart failure was the most prevalent adverse event that was co-prevalent with myocarditis. Corticosteroid therapy alone was the most utilized therapy to treat ICI-related myocarditis. Mortality was seen in nearly half of the patient population. Our study reviewed the preexisting literature of prior reported myocarditis secondary to ICI therapy. Periodic surveillance should be performed by the cardio-oncologist and internist. Due to the expanding role of ICI therapy in treating a variety of cancer patients, appreciation of its impact on the development of myocarditis is needed.
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Affiliation(s)
- Ravi A Thakker
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Marissa A Lee
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Aiham Albaeni
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Krishna H Suthar
- Department of Hematology and Medical Oncology, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Christopher Perez
- Cardiovascular Institute, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Lindsay K Sonstein
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Norman M Farr
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Rohit Venkatesan
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Galveston, TX, USA
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Rafic F Berbarie
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Khaled F Chatila
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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Severe Late-Onset Grade III-IV Adverse Events under Immunotherapy: A Retrospective Study of 79 Cases. Cancers (Basel) 2021; 13:cancers13194928. [PMID: 34638410 PMCID: PMC8508100 DOI: 10.3390/cancers13194928] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary PD-1 inhibitors (nivolumab, pembrolizumab) and anti-CTLA-4 (CD152) (ipilimumab) are widely used in metastatic melanoma. Immunotherapy leads to prolonged lymphocyte effects, which explains the cytotoxicity underlying immune-reaction-based adverse events. Most adverse events (irAEs) occur in the first cycle of treatment at a median of 40 days, but some occur later, over 2 years after immunotherapy is initiated. IrAEs of any grade have been observed in 68.2% of patients and 10% of patients experienced severe grade III/IV irAEs. Data on late-onset irAEs are lacking. We aim to investigate late-onset grade III-IV irAEs and patient characteristics in the context of anti-PD-1 antibody treatment or combination therapy in real-life settings. Abstract Background: For several decades, PD-1 has been a target in malignant melanoma (MM). PD-1 inhibitors (nivolumab, pembrolizumab) and anti-CTLA-4 (CD152) (ipilimumab) have revolutionized cancer therapy. PD-1 and CTLA-4 inhibition leads to prolonged lymphocyte effects, which explains the cytotoxicity underlying immune-reaction-based adverse events (irAEs). Most irAEs occur in the first cycle of treatment at a median of 40 days. IrAEs of any grade have been observed in 68.2% of patients, with 10% of patients experiencing severe grade III/IV irAEs. Data on late-onset irAEs are lacking. Methods: Data on patients with advanced melanoma (N = 1862) from March 2016 to March 2021 were obtained from the RicMel database, a French national multicentric biobank dedicated to the follow-up of MM patients. Patients who received anti-PD-1 therapy or a combination therapy and experienced grade III-IV irAEs were selected and analyzed at 7 months, one year and two years after treatment was initiated. Results: Superficial spreading melanoma (SSM) and previous oncological drug administration before immunotherapy are significant risk factors for late-onset irAEs over 2 years after beginning immunotherapy in the univariate and multivariate analysis. The other parameters—sex, mutational status, association of immunotherapy (PD-1i and CTLA-4i) and overall response—were not significantly associated with late-onset irAEs. In our real-life data study, the median onset time of grade III-IV irAES was 128 days after the initiation of immune checkpoint inhibitors (ICI) therapy. Conclusions: Our study, using real-life data, suggests that patients with SSM and those who have received previous oncological treatments are more likely to experience late-onset grade III-IV irAES. Further multicentric studies with wider recruitment of patients should be performed to confirm our findings, potentially leading to changes in the recommended treatment for carefully monitored at-risk patients.
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