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Khosla A, Sandhu RS, Singhal S, Koka JM. Atezolizumab-Induced Direct Antiglobulin Test-Negative Autoimmune Hemolytic Anemia. Am J Ther 2024; 31:e324-e328. [PMID: 37433054 DOI: 10.1097/mjt.0000000000001645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 07/13/2023]
MESH Headings
- Humans
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/chemically induced
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/immunology
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Coombs Test
- Lung Neoplasms/drug therapy
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Affiliation(s)
- Akshita Khosla
- Department of Internal Medicine, Crozer-Chester Medical Center, Upland, PA
| | | | - Sachi Singhal
- Department of Internal Medicine, Crozer-Chester Medical Center, Upland, PA
| | - Jean-Marie Koka
- Department of Hematology-Oncology, Crozer-Chester Medical Center, Upland, PA
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2
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Javaid A, Bennett C, Rao A, Spain L. Rare Immune-Related Adverse Events (irAEs): Approach to Diagnosis and Management. Pharmaceut Med 2024; 38:25-38. [PMID: 38194017 PMCID: PMC10824871 DOI: 10.1007/s40290-023-00508-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2023] [Indexed: 01/10/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionised the treatment landscape across many solid organ malignancies and form part of routine clinical practice in many tumours. As indications for monotherapy, doublet therapy and combination approaches with chemotherapy and targeted agents expand, clinicians must be aware of the wide range of possible immune-related adverse events (irAEs). Common toxicities, including rash, colitis, hepatitis and pneumonitis are well described in the literature, and have established diagnostic and management algorithms. Rarer toxicities, often with an incidence of less than 1%, are less defined. These syndromes can be poorly recognised, may take on a fulminant course and do not have established or evidence-based diagnostic and management strategies. As such, patients may experience increased morbidity, mortality and poorer outcomes, related both to these irAEs as well as how the treatment of these may affect the management of their underlying malignancy. In this review, we aim to explore the incidence, potential biomarkers, pathogenesis, diagnostic work-up and clinical sequelae of a selection of uncommon irAEs, with a focus on myocarditis, neurological and haematologic syndromes. Further prospective research is required to accurately define the incidence and pathogenesis of these conditions, with the aim of increasing clinician awareness of rare irAEs and to assist with a more personalised and mechanism-based approach to these syndromes.
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Affiliation(s)
- Anadil Javaid
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Catherine Bennett
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Aparna Rao
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Lavinia Spain
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, Melbourne, VIC, Australia.
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3
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Dirven I, Vander Mijnsbrugge AS, Mignon S, Tijtgat J, Kint N, Neyns B. Auto-immune hemolytic anemia and hemophagocytic lymphohistiocytosis as immune-related adverse event in patients with metastatic melanoma and concurrent chronic lymphocytic leukemia: a case series and literature review. Melanoma Res 2023; 33:338-344. [PMID: 37114670 DOI: 10.1097/cmr.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Auto-immune hemolytic anemia (AIHA) and hemophagocytic lymphohistiocytosis (HLH) are both rare immune-related adverse events (irAEs) following treatment with immune checkpoint inhibitors. Consensus treatment guidelines are currently lacking. Patients with a solid malignancy and a concurrent lymphoproliferative disorder, such as chronic lymphocytic leukemia (CLL), might be more prone to develop hematological irAEs. We report the case history of two patients, diagnosed with CLL, who during treatment for metastatic melanoma with nivolumab, a PD-1 immune checkpoint blocking mAb, developed AIHA and HLH in combination with AIHA. Furthermore, we provide a review of the literature on published cases of immune-related AIHA and HLH and their correlation with CLL.
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MESH Headings
- Humans
- Melanoma/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphohistiocytosis, Hemophagocytic/chemically induced
- Lymphohistiocytosis, Hemophagocytic/complications
- Skin Neoplasms
- Anemia, Hemolytic
- Neoplasms, Second Primary
- Anemia, Hemolytic, Autoimmune/chemically induced
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Affiliation(s)
- Iris Dirven
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
| | - An-Sofie Vander Mijnsbrugge
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
| | - Sacha Mignon
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
| | - Jens Tijtgat
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
| | - Nicolas Kint
- Department of Hematology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Bart Neyns
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
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Kazemzadeh K, Behrouzieh S, Rezaei N. Shedding light on the side effects of immunotherapies used for leukemia: an updated review of the literature. Expert Rev Anticancer Ther 2023; 23:1193-1204. [PMID: 37812581 DOI: 10.1080/14737140.2023.2267760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Leukemia is an abnormal clonal development of leukemic cells originating from the bone marrow, which is widely known for its significant prevalence and mortality rate. Chemotherapy, surgery, radiation, and combination therapies have been its routine therapeutic methods; however, the advent of cancer immunotherapy is known as revolutionary for its higher efficacy and lesser toxicity. AREAS COVERED Immunotherapy boosts the body's immune system by using components from other living organisms. Although immunotherapy seems to be safer than chemotherapy, many studies have noticed different immune-related side effects in various body systems (e.g. cardiovascular, neurologic) which we have reviewed in this investigation as the main goal. We tried to describe immunotherapy-related side effects in human body systems in detail. EXPERT OPINION Being aware of these side effects leads to better clinical decision-making for each individual, and a one-step-ahead management in case of occurrence. We also briefly discussed the role of immunotherapy in treating leukemia as one of the most prevalent cancers in children and tried to emphasize that it is crucial to monitor adverse events as they may remain obscure until adolescence.
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Affiliation(s)
- Kimia Kazemzadeh
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Network of Neurosurgery and Artificial Intelligence (NONAI), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Sadra Behrouzieh
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Neurosurgery and Artificial Intelligence (NONAI), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Immune-Related Uncommon Adverse Events in Patients with Cancer Treated with Immunotherapy. Diagnostics (Basel) 2022; 12:diagnostics12092091. [PMID: 36140493 PMCID: PMC9498261 DOI: 10.3390/diagnostics12092091] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/06/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Immunotherapy has dramatically changed the therapeutic landscape of oncology, and has become standard of care in multiple cancer types in front or late lines of therapy, with some longstanding responses and outstanding results. Notwithstanding, its use has brought a totally unique spectrum of adverse events, characterized by a myriad of diverse manifestations affecting nearly every organ and system of the body, including the endocrine, nervous, cardiac, respiratory and gastrointestinal systems. Uncommon adverse events, defined as those occurring in less than 1% of patients, comprise an even more heterogeneous group of diseases that are being seen more recurrently as the use of immune check-point inhibitors increases and indications spread in different tumor types and stages. Here, we comprehensively review some uncommon, but exceedingly important, immune-related adverse events, with special emphasis in the clinical approach and diagnostic workup, aiming to reunite the evidence published previously, allowing an increase in awareness and knowledge from all specialists implicated in the diagnosis, treatment, and care of cancer patients treated with immunotherapy.
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Wilson NR, Lockhart JR, Garcia-Perdomo HA, Oo TH, Rojas-Hernandez CM. Management and Outcomes of Hematological Immune-related Adverse Events: Systematic Review and Meta-analysis. J Immunother 2022; 45:13-24. [PMID: 34469413 DOI: 10.1097/cji.0000000000000390] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
Data regarding clinical outcomes and management of hematological manifestations of immune checkpoint inhibition (ICI) is limited to case reports, series, and a few retrospective reviews. We aimed to determine the rate of response of hematological immune-related adverse events (irAEs) to immunosuppressive therapy. MEDLINE (OVID), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to the present day. Retrospective reports were included without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. The primary outcome of this study was the rate of response to immunosuppression. Eighty studies (14 case series and 66 individual case reports) were analyzed with a total of 135 patients with ICI-related hematological irAEs. Data analysis showed an average proportional response rate to immunosuppression among hematological irAE entities of 50% (range: 25%-70%). The heterogeneity index (I2) was 0% among reports within each entity. There is a wide spectrum of hematological manifestations to ICI therapy, and to date there is no large randomized-controlled trial data to evaluate the efficacy of treatment strategies for hematological irAEs. We found a variable overall response rate to immunosuppression therapy of around 50%, without statistically significant heterogeneity among different irAE types but significant differences among the different countries of publication. Future studies evaluating the optimal dose and duration of immunosuppressive agents for patients with hematological irAEs should be undertaken.
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Affiliation(s)
- Nathaniel R Wilson
- Department of Internal Medicine, The University of Texas McGovern Medical School
| | | | | | - Thein H Oo
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Jobson D, McCormack CJ, Hiscutt E, Tam C. Severe treatment-resistant autoimmune haemolytic anaemia following ipilimumab in a patient with metastatic melanoma and CLL. Leuk Lymphoma 2020; 62:992-994. [PMID: 33222565 DOI: 10.1080/10428194.2020.1846735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Dale Jobson
- Department of Dermatology, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Edinburgh, Edinburgh, United Kingdom
| | - Christopher J McCormack
- Department of Dermatology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Emma Hiscutt
- Department of Dermatology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Constantine Tam
- Haematology Department, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
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Michot JM, Lazarovici J, Tieu A, Champiat S, Voisin AL, Ebbo M, Godeau B, Michel M, Ribrag V, Lambotte O. Haematological immune-related adverse events with immune checkpoint inhibitors, how to manage? Eur J Cancer 2019; 122:72-90. [PMID: 31634647 DOI: 10.1016/j.ejca.2019.07.014] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 01/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are changing the treatments of many patients with cancer. These immunotherapies are generally better tolerated than chemotherapy, and their adverse events are immune-related mimicking autoimmune or inflammatory conditions. Although these immune-related adverse events mainly affect the skin, endocrine glands, digestive tract, joints, liver or lungs, all the organs can be theoretically affected, and the haematopoietic system is not spared. This review of the literature will focus on the haematological immune-related adverse events (Haem-irAEs). By reviewing the largest clinical trials of ICIs, we estimate the frequency of Haem-irAEs at 3.6% for all grades and 0.7% for grades III-IV. Frequency of Haem-irAEs of all grades was found to be higher with anti-programmed cell death 1 (4.1%) or anti-programmed cell death ligand 1 (4.7%) than with anti-cytotoxic T-lymphocyte-associated protein 4 (0.5%) (p < 0.0001). From the 63 cases with Haem-irAEs reported in the literature, the mean time to the onset was found to be 10 weeks after ICI initiation, and the large range for occurrence (1-84 weeks) and the regular incidence suggest that Haem-irAEs could occur at any time after ICI therapy. Among the 63 reported cases with Haem-irAEs, the distribution was immune thrombocytopenia (n = 18, 29%), pancytopenia or immune aplastic anaemia (n = 12, 19%), neutropenia (n = 11, 17%), haemolytic anaemia (n = 10, 16%), cytokine release syndrome with haemophagocytic syndrome (n = 7, 11%) and other Haem-irAEs including bicytopenia or pure red cell aplasia (n = 5, 8%). Haem-irAEs are generally highly severe adverse reactions with a mortality rate of Haem-irAEs reported to be 14% (9 deaths among the 63 cases reported). The more severe and life-threatening Haem-irAEs were both cytokine release syndrome with haemophagocytic syndrome and pancytopenia or aplastic anaemia. Haem-irAEs induced by ICIs are potentially life-threatening. By discussing their pathophysiological aspects and clinical picture, we propose in this review clinical guidelines for management.
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Affiliation(s)
- J M Michot
- Gustave Roussy, Université Paris-Saclay, Département des Innovations Thérapeutiques et Essais Précoces, Villejuif, F-94805, France; Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, Le Kremlin-Bicêtre, F-94275, France.
| | - J Lazarovici
- Gustave Roussy, Université Paris-Saclay, Département D'Hématologie, Villejuif, F-94805, France
| | - A Tieu
- Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, Le Kremlin-Bicêtre, F-94275, France
| | - S Champiat
- Gustave Roussy, Université Paris-Saclay, Département des Innovations Thérapeutiques et Essais Précoces, Villejuif, F-94805, France
| | - A L Voisin
- Gustave Roussy, Université Paris-Saclay, Unité de Pharmacovigilance, Villejuif, F-94805, France
| | - M Ebbo
- Assistance Publique - Hôpitaux de Marseille, Hôpital de La Timone, Médecine Interne, Marseille, F-13005, France
| | - B Godeau
- Assistance Publique - Hôpitaux de Paris, Hôpital Henri Mondor, Médecine Interne, Centre de Référence des Cytopénies Auto-immunes de L'Adulte, Université Paris-Est Créteil, Créteil, F-94010, France
| | - M Michel
- Assistance Publique - Hôpitaux de Paris, Hôpital Henri Mondor, Médecine Interne, Centre de Référence des Cytopénies Auto-immunes de L'Adulte, Université Paris-Est Créteil, Créteil, F-94010, France
| | - V Ribrag
- Gustave Roussy, Université Paris-Saclay, Département des Innovations Thérapeutiques et Essais Précoces, Villejuif, F-94805, France; Gustave Roussy, Université Paris-Saclay, Département D'Hématologie, Villejuif, F-94805, France
| | - O Lambotte
- Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, Le Kremlin-Bicêtre, F-94275, France; INSERM U1184, Immunology of Viral Infections and Autoimmune Diseases, Le Kremlin-Bicêtre, F-94276, France; Université Paris Sud, UMR 1184, Le Kremlin-Bicêtre, F-94276, France; CEA, DSV/iMETI, IDMIT, Fontenay-aux-Roses, F-92265, France
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Tanios GE, Doley PB, Munker R. Autoimmune hemolytic anemia associated with the use of immune checkpoint inhibitors for cancer: 68 cases from the Food and Drug Administration database and review. Eur J Haematol 2018; 102:157-162. [DOI: 10.1111/ejh.13187] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/13/2018] [Accepted: 10/15/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Georges E. Tanios
- Section of Hematology and Medical Oncology Tulane University New Orleans Louisiana
| | - Peter B. Doley
- Section of Hematology and Medical Oncology Tulane University New Orleans Louisiana
| | - Reinhold Munker
- Section of Hematology and Medical Oncology Tulane University New Orleans Louisiana
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