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Shah J, Devalaraju S, Baerman E, Lee IJA, Takigawa K, Machado AP, Catinis C, Shatila M, Varatharajalu K, Shafi M, Lee HC, Strati P, Thomas A, Wang Y. Gastrointestinal toxicities of proteasome inhibitor therapy. J Cancer Res Clin Oncol 2024; 150:334. [PMID: 38969842 PMCID: PMC11226465 DOI: 10.1007/s00432-024-05716-3] [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: 02/10/2024] [Accepted: 03/20/2024] [Indexed: 07/07/2024]
Abstract
PURPOSE Proteasome inhibitors (PIs), which cause cell death via tumor suppressor and pro-apoptotic proteins, are integral to treatment of many hematologic malignancies but are limited by their gastrointestinal adverse effects. Evidence regarding these PI-related adverse effects is scant. In this study, we evaluated gastrointestinal adverse events caused by PIs and compared gastrointestinal toxicities between bortezomib, carfilzomib, and ixazomib. METHODS We conducted a retrospective study of cancer patients treated with PIs at a tertiary care cancer center to investigate the clinical characteristics of PI-related gastrointestinal adverse events. RESULTS Our sample comprised 973 patients with PI exposure and stool studies ordered between January 2017 and December 2022. Of these, 193 patients (20%) had PI-related gastrointestinal toxicity based on clinical symptoms and stool study results. The most common symptom was diarrhea, present in 169 (88% of those with gastrointestinal toxicity). Twenty-two (11%) required hospitalization, and 71 (37%) developed recurrence of symptoms. Compared to bortezomib or carfilzomib, ixazomib had a longer interval from PI initiation to the onset of gastrointestinal symptoms (313 days vs 58 days vs 89 days, p = 0.002) and a significantly lower percentage of diarrhea-predominant presentation of gastrointestinal toxicity (71% vs 96% vs 91%, p = 0.048). CONCLUSION While PI-related gastrointestinal toxicities have various presentations and courses based on different regimens, the vast majority of patients presented with milder disease behavior. Despite a considerably high rate of hospitalization and recurrence after treatment necessitating optimization of clinical management, our cohort demonstrates favorable outcomes without long-term consequences.
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Affiliation(s)
- Jay Shah
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Elliot Baerman
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Irene Jeong-Ah Lee
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kei Takigawa
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Antonio Pizuorno Machado
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, TX, USA
| | - Christine Catinis
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, TX, USA
| | - Malek Shatila
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Krishnavathana Varatharajalu
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Mehnaz Shafi
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Hans C Lee
- Department of Lymphoma-Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paolo Strati
- Department of Lymphoma-Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anusha Thomas
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA.
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Hirata Y, Tanaka Y, Yokota H, Ohno H, Nishida K, Shimizu H, Mizuta N, Nakazawa K, Koshiba R, Kakimoto K, Miyazaki T, Nakamura S, Nishikawa H. Gut microbiota shifts from onset to remission in immune checkpoint inhibitor-induced enterocolitis: a case report. Gut Pathog 2024; 16:33. [PMID: 38965595 PMCID: PMC11225377 DOI: 10.1186/s13099-024-00630-y] [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: 04/24/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are crucial in cancer treatment; however, they carry the risk of immune-related adverse events (irAEs), such as enteritis. CASE PRESENTATION This study investigated the role of the gut microbiota during the onset and remission of irAE enteritis in a patient with stage IV melanoma undergoing anti-PD-1 and anti-CTLA-4 therapy. Following commencement of ICI treatment, the patient developed severe diarrhea and was diagnosed with grade 3 irAE enteritis. Steroid and probiotic treatments provided swift symptom relief and remission, as confirmed by reduced fecal calprotectin levels and gastrointestinal imaging. Microbiota diversity analysis conducted via 16S rRNA gene sequencing identified a decrease in Streptococcus prevalence with improvement in enteritis symptoms. Conversely, genera Fusobacterium, Faecalibacterium, Bacteroides, Prevotella, and Bifidobacterium showed increased representation after remission. These genera are associated with anti-inflammatory properties and fibrous substrate degradation, aiding gut health. Immunological assessment demonstrated fluctuations in cytokine expression and the modulation of costimulatory molecules, aligning with therapeutic interventions and microbiota alterations. CONCLUSIONS Our findings indicate a significant correlation between gut microbiota and immune responses in irAE enteritis. This underscores the potential utility of microbiome profiling in predicting irAE occurrence and in providing treatment strategies, thereby promoting a more comprehensive approach to managing the adverse effects of ICIs.
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Affiliation(s)
- Yuki Hirata
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan.
| | | | | | | | - Koji Nishida
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Hikaru Shimizu
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Noboru Mizuta
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Kei Nakazawa
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Ryoji Koshiba
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Kazuki Kakimoto
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Takako Miyazaki
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Shiro Nakamura
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Hiroki Nishikawa
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
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Del Gaudio A, Di Vincenzo F, Petito V, Giustiniani MC, Gasbarrini A, Scaldaferri F, Lopetuso LR. Focus on Immune Checkpoint Inhibitors-related Intestinal Inflammation: From Pathogenesis to Therapeutical Approach. Inflamm Bowel Dis 2024; 30:1018-1031. [PMID: 37801695 PMCID: PMC11144981 DOI: 10.1093/ibd/izad229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Indexed: 10/08/2023]
Abstract
Recently, antitumor immunotherapies have witnessed a breakthrough with the emergence of immune checkpoint inhibitors (ICIs) including programmed cell death-1 (PD-1), programmed cell death-ligand 1 (PD-L1), and cytotoxic T lymphocyte antigen 4 (CTLA-4) inhibitors. Unfortunately, the use of ICIs has also led to the advent of a novel class of adverse events that differ from those of classic chemotherapeutics and are more reminiscent of autoimmune diseases, the immune-related adverse events (IRAEs). Herein, we performed an insight of the main IRAEs associated with ICIs, focusing on gastroenterological IRAEs and specifically on checkpoint inhibitor colitis, which represents the most widely reported IRAE to date. We comprehensively dissected the current evidence regarding pathogenesis, diagnosis, and management of ICIs-induced colitis, touching upon also on innovative therapies.
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Affiliation(s)
- Angelo Del Gaudio
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Federica Di Vincenzo
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Valentina Petito
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | | | - Antonio Gasbarrini
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Franco Scaldaferri
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
| | - Loris Riccardo Lopetuso
- UOS Malattie Infiammatorie Croniche Intestinali, Centro di Malattie dell’Apparato Digerente (CEMAD), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italy
- Department of Medicine and Ageing Sciences, G. d’Annunzio University of Chieti-Pescara, Chieti, 66100, Italy
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, Chieti, 66100, Italy
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Townsend MJ, Benque IJ, Li M, Grover S. Review article: Contemporary management of gastrointestinal, pancreatic and hepatic toxicities of immune checkpoint inhibitors. Aliment Pharmacol Ther 2024; 59:1350-1365. [PMID: 38590108 DOI: 10.1111/apt.17980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/13/2023] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are effective oncologic agents which frequently cause immune-related adverse events (irAEs) which can impact multiple organ systems. Onco-Gastroenterology is a novel and emerging subspecialty within gastroenterology focused on cancer treatment-related complications. Gastroenterologists must be prepared to identify and manage diverse immune-mediated toxicities including enterocolitis, hepatitis, pancreatitis and other ICI-induced toxicities. AIM To provide a narrative review of the epidemiology, diagnostic evaluation and management of checkpoint inhibitor-induced gastrointestinal and hepatic toxicities. METHODS We searched Cochrane and PubMed databases for articles published through August 2023. RESULTS Gastrointestinal and hepatic irAEs include most commonly enterocolitis and hepatitis, but also pancreatitis, oesophagitis, gastritis, motility disorders (gastroparesis) and other rarer toxicities. Guidelines from the National Comprehensive Cancer Network, American Society of Clinical Oncology and European Society for Medical Oncology, in combination with emerging cohort and clinical trial data, offer strategies for management of ICI toxicities. Evaluation of irAEs severity by formal classification and clinical stability, and a thorough workup for alternative etiologies which may clinically mimic irAEs underlie initial management. Treatments include corticosteroids, biologics and other immunosuppressive agents plus supportive care; decisions on dosing, timing and choice of steroid adjuncts and potential for subsequent checkpoint inhibitor dosing are nuanced and toxicity-specific. CONCLUSIONS Expanding clinical trial and cohort data have clarified the epidemiology and clinical characteristics of gastrointestinal, pancreatic and hepatic toxicities of ICIs. Guidelines, though valuable, remain based principally on retrospective cohort data. Quality prospective, controlled studies may refine algorithms for treatment and potential immunotherapy rechallenge.
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Affiliation(s)
- Matthew J Townsend
- Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Isaac J Benque
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Michael Li
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Division of Gastroenterology, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Shilpa Grover
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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5
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Riveiro-Barciela M, Carballal S, Díaz-González Á, Mañosa M, Gallego-Plazas J, Cubiella J, Jiménez-Fonseca P, Varela M, Menchén L, Sangro B, Fernández-Montes A, Mesonero F, Rodríguez-Gandía MÁ, Rivera F, Londoño MC. Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:401-432. [PMID: 38228461 DOI: 10.1016/j.gastrohep.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/28/2023] [Accepted: 10/19/2023] [Indexed: 01/18/2024]
Abstract
The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2% to 40%, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona (UAB), Department of Medicine, Spain.
| | - Sabela Carballal
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Universitat de Barcelona, Spain
| | - Álvaro Díaz-González
- Gastroenterology Department, Grupo de Investigación Clínica y Traslacional en Enfermedades Digestivas, Instituto de Investigación Valdecilla (IDIVAL), Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Míriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Joaquín Cubiella
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Universitario de Ourense, Grupo de Investigación en Oncología Digestiva-Ourense, Spain
| | - Paula Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - María Varela
- Gastroenterology Department, Hospital Universitario Central de Asturias, IUOPA, ISPA, FINBA, University of Oviedo, Oviedo, Spain
| | - Luis Menchén
- Servicio de Aparato Digestivo - CEIMI, Instituto de Investigación Sanitaria Gregorio, Marañón, Spain; Departamento de Medicina, Universidad Complutense, Madrid, Spain
| | - Bruno Sangro
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Cancer Center Clinica Universidad de Navarra, Pamplona-Madrid, Spain
| | - Ana Fernández-Montes
- Medical Oncology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Francisco Mesonero
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Universidad de Alcalá de Henares, Spain
| | - Miguel Ángel Rodríguez-Gandía
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRyCIS), Madrid, Spain
| | - Fernando Rivera
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - María-Carlota Londoño
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat de Barcelona, Spain; Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Spain
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Mok K, Wu C, Chan S, Wong G, Wong VWS, Ma B, Lui R. Clinical Management of Gastrointestinal and Liver Toxicities of Immune Checkpoint Inhibitors. Clin Colorectal Cancer 2024; 23:4-13. [PMID: 38172003 DOI: 10.1016/j.clcc.2023.12.003] [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: 11/02/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024]
Abstract
Immune checkpoint inhibitors have transformed the treatment paradigm for various types of cancer. Nonetheless, with the utilization of these groundbreaking treatments, immune-related adverse events (irAEs) are increasingly encountered. Colonic and hepatic involvement are among the most frequently encountered irAEs. Drug-induced side effects, infectious causes, and tumor-related symptoms are the key differentials for irAE complications. Potential risk factors for the development of irAEs include combination use of immune checkpoint inhibitors, past development of irAEs with other immunotherapy treatments, certain concomitant drugs, and a pre-existing personal or family history of autoimmune illness such as inflammatory bowel disease. The importance of early recognition, timely and proper management cannot be understated, as there are profound clinical implications on the overall cancer treatment plan and prognosis once these adverse events occur. Herein, we cover the clinical management of the well-established gastrointestinal irAEs of enterocolitis and hepatitis, and also provide an overview of several other emerging entities.
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Affiliation(s)
- Kevin Mok
- Department of Clinical Oncology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Claudia Wu
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Stephen Chan
- State Key Laboratory of Translational Oncology, Department of Clinical Oncology, Sir YK Pao Centre for Cancer, Hong Kong Cancer Institute, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Grace Wong
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent Wai-Sun Wong
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Brigette Ma
- Department of Clinical Oncology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Rashid Lui
- Department of Clinical Oncology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong SAR, China.
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Velikova T, Krastev B, Gulinac M, Zashev M, Graklanov V, Peruhova M. New strategies in the diagnosis and treatment of immune-checkpoint inhibitor-mediated colitis. World J Clin Cases 2024; 12:1050-1062. [PMID: 38464930 PMCID: PMC10921308 DOI: 10.12998/wjcc.v12.i6.1050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 02/20/2024] Open
Abstract
Immune-checkpoint inhibitor-mediated colitis (IMC) is an increasingly recognized adverse event in cancer immunotherapy, particularly associated with immune checkpoint inhibitors (ICIs) such as anti-cytotoxic T-lymphocyte antigen-4 and anti-programmed cell death protein-1 antibodies. As this revolutionary immunotherapy gains prominence in cancer treatment, understanding, diagnosing, and effectively managing IMC becomes paramount. IMC represents a unique challenge due to its immune-mediated nature and potential for severe complications. However, a precise picture of IMC pathophysiology is currently unavailable. Therefore, we aimed to summarize the existing data while acknowledging the need for further research. This comprehensive review explores the mechanisms underlying ICIs, gastrointestinal adverse effects, and, in particular, IMC's incidence, prevalence, and features. Our review also emphasizes the importance of recognizing IMC's distinct clinical and histopathological features to differentiate it from other forms of colitis. Furthermore, this paper highlights the urgent need for evolving diagnostic methods, therapeutic strategies, and a multidisciplinary approach to effectively manage IMC.
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Affiliation(s)
- Tsvetelina Velikova
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
| | - Boris Krastev
- Medical Center Nadezhda, Medical Center Nadezhda, Sofia 1407, Bulgaria
| | - Milena Gulinac
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
- General and Clinical Pathology, Medical University of Plovdiv, Plovdiv 4002, Bulgaria
| | - Miroslav Zashev
- Department of General Surgery, University Hospital “Heart and Brain”, Burgas 8000, Bulgaria
| | - Vasko Graklanov
- First Department of Internal Diseases, Medical University of Plovdiv, Plovdiv 4000, Bulgaria
- Department of Hematology, University Hospital “St. George”, Plovdiv 4000, Bulgaria
| | - Milena Peruhova
- Division of Gastroenterology, University Hospital “Heart and Brain”, Burgas 1000, Bulgaria
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8
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Riveiro-Barciela M, Carballal S, Díaz-González Á, Mañosa M, Gallgo-Plazas J, Cubiella J, Jiménez-Fonseca P, Varela M, Menchén L, Sangro B, Fernández-Montes A, Mesonero F, Rodríguez-Gandía MÁ, Rivera F, Londoño MC. Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:83-113. [PMID: 38226597 DOI: 10.17235/reed.2024.10250/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2 % to 40 %, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events.
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Affiliation(s)
| | | | | | - Miriam Mañosa
- Gastroenterology, Hospital Universitari Germans Trias i Pujol
| | | | | | | | - María Varela
- Gastroenterology, Hospital Universitario Central de Asturias
| | - Luis Menchén
- Digestive Diseases, Instituto de Investigación Sanitaria Gregorio Marañón
| | | | | | | | | | - Fernando Rivera
- Hospital Universitario Marqués de Valdecilla, Medical Oncology
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Ding M, Zhang X, Wang J, Gao F, Zheng X, Yuan J, Qi X. Treatment and outcomes of immune checkpoint inhibitors-associated colitis/diarrhea: A systematic review and meta-analysis. Dig Liver Dis 2023; 55:1621-1631. [PMID: 36894390 DOI: 10.1016/j.dld.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/15/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have improved the outcomes of cancer patients. However, ICIs often lead to colitis/diarrhea. This study aimed to assess the treatment of ICIs-associated colitis/diarrhea and outcomes. METHODS PubMed, EMBASE, and Cochrane Library databases were searched for eligible studies which investigated the treatment and outcomes of colitis/diarrhea developing in patients who received ICIs. The pooled incidences of any-grade colitis/diarrhea, low-grade colitis, high-grade colitis, low-grade diarrhea, and high-grade diarrhea as well as the pooled rates of response to treatment, mortality, and ICIs permanent discontinuation and restarts in patients with ICIs-associated colitis/diarrhea were estimated using a random-effects model. RESULTS Among the 11,492 papers initially identified, 27 studies were included. The pooled incidences of any-grade colitis/diarrhea, low-grade colitis, high-grade colitis, low-grade diarrhea, and high-grade diarrhea were 17%, 3%, 17%, 13%, and 15%, respectively. The pooled rates of overall response, response to corticosteroid therapy, and response to biological agents were 88%, 50%, and 96%, respectively. The pooled short-term mortality in patients with ICIs-associated colitis/diarrhea was 2%. The pooled incidences of ICIs permanent discontinuation and restarts were 43% and 33%, respectively. CONCLUSION ICIs-associated colitis/diarrhea is common, but rarely lethal. Half of them are responsive to corticosteroid therapy. There is a fairly high rate of response to biological agents in steroid-refractory colitis/diarrhea patients.
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Affiliation(s)
- Min Ding
- Meta-Analysis Interest Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China; Postgraduate College, China Medical University, Shenyang, China
| | - Xianxian Zhang
- Meta-Analysis Interest Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China; Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Jing Wang
- Meta-Analysis Interest Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China; Department of Gastroenterology, The 960th Hospital of the PLA, Jinan, China
| | - Fangbo Gao
- Meta-Analysis Interest Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China; Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Xiaojie Zheng
- Meta-Analysis Interest Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China; Postgraduate College, China Medical University, Shenyang, China
| | - Jinqiu Yuan
- Clinical Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Xingshun Qi
- Meta-Analysis Interest Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China; Postgraduate College, China Medical University, Shenyang, China; Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China.
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10
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Saji A, Chopra M, Jacob J, Altan M, Alhalabi O, Shah AY, Qiao W, Wang Y, Thomas A. Implementing an immunotherapy toxicity (IOTOX) GI service improves outcomes in patients with immune-mediated diarrhea and colitis. J Cancer Res Clin Oncol 2023; 149:5841-5852. [PMID: 36585982 PMCID: PMC9803881 DOI: 10.1007/s00432-022-04504-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/29/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but can lead to GI toxicity, termed immune-mediated diarrhea and colitis (IMDC). Standardization of IMDC management and early GI consultation is imperative to control symptoms and prevent delays in cancer care. Therefore, we implemented an inpatient algorithm and a focused IOTOX GI service to measure outcomes. METHODS Patients who received ICIs and were hospitalized with severe IMDC were grouped into a pre-interventional cohort in 2017, followed by implementation of the standardized algorithm in 2018, and then a post-interventional cohort of patients in 2019. Clinical data and patient outcomes were compared using univariate and multivariate analysis to determine the morbidity, and overall survival. RESULTS Our sample comprised 126 hospitalized patients with IMDC, with 59 patients in the pre-interventional 2017 cohort, and 67 patients in the post-interventional 2019 cohort. We found no significant differences in the clinical severity of IMDC symptoms between the two cohorts (p = 1.03) or median time from ICI exposure to development of IMDC (p = 0.495, respectively). After implementing the standardized algorithm, we observed higher rates of GI consultation (p < 0.001) in the post-treatment group. Patients in the post-treatment cohort showed decreased time to clinical remission (4 vs 10 days, p = 0.046), higher rate of GI follow-up after hospital discharge (p = 0.038), fewer hospital re-admissions (p = 0.002), and significantly fewer recurrences of IMDC symptoms (p = 0.002). Overall survival was significantly higher for at least 2 years in patients who followed with GI post-discharge compared to those without follow-up (p = 0.003). CONCLUSION Prompt GI consultation and monitoring of IMDC using a regimented approach can provide efficacious management, decrease time to clinical remission of symptoms, decrease re-admissions to the hospital, and improve overall patient outcomes.
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Affiliation(s)
- Alice Saji
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX 77079 USA
| | - Maneera Chopra
- Division of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jake Jacob
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX USA
| | - Mehmet Altan
- Department of Thoracic, Head and Neck Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX USA
| | - Omar Alhalabi
- Department of Genitourinary Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX USA
| | - Amishi Yogesh Shah
- Department of Genitourinary Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX USA
| | - Wei Qiao
- Department of Biostatistics, The University of M.D. Anderson Cancer Center, Houston, TX USA
| | - Yinghong Wang
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX 77079 USA
| | - Anusha Thomas
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX 77079 USA
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11
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Terrin M, Migliorisi G, Dal Buono A, Gabbiadini R, Mastrorocco E, Quadarella A, Repici A, Santoro A, Armuzzi A. Checkpoint Inhibitor-Induced Colitis: From Pathogenesis to Management. Int J Mol Sci 2023; 24:11504. [PMID: 37511260 PMCID: PMC10380448 DOI: 10.3390/ijms241411504] [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: 05/20/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
The advent of immunotherapy, specifically of immune checkpoint inhibitors (ICIs), for the treatment of solid tumors has deeply transformed therapeutic algorithms in medical oncology. Approximately one-third of patients treated with ICIs may de velop immune-related adverse events, and the gastrointestinal tract is often affected by different grades of mucosal inflammation. Checkpoint inhibitors colitis (CIC) presents with watery or bloody diarrhea and, in the case of severe symptoms, requires ICIs discontinuation. The pathogenesis of CIC is multifactorial and still partially unknown: anti-tumor activity that collaterally effects the colonic tissue and the upregulation of specific systemic inflammatory pathways (i.e., CD8+ cytotoxic and CD4+ T lymphocytes) are mainly involved. Many questions remain regarding treatment timing and options, and biological treatment, especially with anti-TNF alpha, can be offered to these patients with the aim of rapidly resuming oncological therapies. CIC shares similar pathogenesis and aspects with inflammatory bowel disease (IBD) and the use of ICI in IBD patients is under evaluation. This review aims to summarize the pathogenetic mechanism underlying CIC and to discuss the current evidenced-based management options, including the role of biological therapy, emphasizing the relevant clinical impact on CIC and the need for prompt recognition and treatment.
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Affiliation(s)
- Maria Terrin
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Giulia Migliorisi
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Arianna Dal Buono
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
| | - Roberto Gabbiadini
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
| | - Elisabetta Mastrorocco
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Alessandro Quadarella
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Medical Oncology and Haematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Armuzzi
- IBD Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.T.); (G.M.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
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12
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Desmedt V, Jauregui-Amezaga A, Fierens L, Aspeslagh S, Dekervel J, Wauters E, Peeters M, Sabino J, Crapé L, Somers M, Hoorens A, Dutré J, Lobatón T. Position statement on the management of the immune checkpoint inhibitor-induced colitis via multidisciplinary modified Delphi consensus. Eur J Cancer 2023; 187:36-57. [PMID: 37116287 DOI: 10.1016/j.ejca.2023.03.025] [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: 07/20/2022] [Revised: 02/10/2023] [Accepted: 03/23/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION The use of immune checkpoint inhibitors (ICIs) in cancer immunotherapy has shown increased overall survival in a wide range of cancer types with the associated risk of developing severe immune-mediated adverse events, commonly involving the gastrointestinal tract. AIM The aim of this position statement is to provide an updated practice advice to the gastroenterologists and oncologists on the diagnosis and management of ICI-induced gastrointestinal toxicity. METHODOLOGY The evidence reviewed in this paper includes a comprehensive search strategy of English language publications. Consensus was reached using a three-round modified Delphi methodology and approved by the members of the Belgian Inflammatory Bowel Disease Research and Development Group (BIRD), Belgian Society of Medical Oncology (BSMO), Belgian group of Digestive Oncology (BGDO), and Belgian Respiratory Society (BeRS). CONCLUSIONS The management of ICI-induced colitis requires an early multidisciplinary approach. A broad initial assessment is necessary (clinical presentation, laboratory markers, endoscopic and histologic examination) to confirm the diagnosis. Criteria for hospitalisation, management of ICIs, and initial endoscopic assessment are proposed. Even if corticosteroids are still considered the first-line therapy, biologics are recommended as an escalation therapy and as early treatment in patients with high-risk endoscopic findings.
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Affiliation(s)
- Valérie Desmedt
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Belgium
| | - Aranzazu Jauregui-Amezaga
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Belgium; Laboratory of Experimental Medicine and Pediatrics (LEMP), Division of Gastroenterology-Hepatology, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium.
| | - Liselotte Fierens
- Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Catholic University of Leuven, Belgium
| | | | - Jeroen Dekervel
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Belgium
| | - Els Wauters
- Respiratory Oncology Unit (Pulmonology), University Hospitals KU Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Marc Peeters
- Department of Digestive Oncology, University Hospital Antwerp, Belgium
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Belgium
| | - Lara Crapé
- Department of Gastroenterology, Algemeen Stedelijk Ziekenhuis Aalst, Belgium
| | - Michael Somers
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Belgium
| | - Anne Hoorens
- Department of Pathology, University Hospital Ghent, Belgium
| | - Joris Dutré
- Department of Gastroenterology, Ziekenhuis Netwerk Antwerpen Jan Palfijn, Belgium
| | - Triana Lobatón
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
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13
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Liu C, Shatila M, Mathew A, Machado AP, Thomas A, Zhang HC, Thomas AS, Faleck D, Funchain P, Philpott J, Grivas P, Obeid M, Carbonnel F, Wang Y. Role of C-Reactive Protein in Predicting the Severity and Response of Immune-Mediated Diarrhea and Colitis in Patients with Cancer. J Cancer 2023; 14:1913-1919. [PMID: 37476185 PMCID: PMC10355204 DOI: 10.7150/jca.84261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/07/2023] [Indexed: 07/22/2023] Open
Abstract
Background: Immune-mediated diarrhea and colitis (IMDC) frequently develop after treatment with immune checkpoint inhibitors. C-reactive protein (CRP) is a serum inflammatory biomarker used to stratify and monitor disease severity in many inflammatory conditions. However, CRP level is not specific and is widely influenced by various factors non-specific to bowel inflammation. We aimed to study the utility of CRP as a predictor of disease severity and therapy response in IMDC. Methods: We performed a retrospective analysis of patients diagnosed with IMDC who had CRP measured at IMDC onset and after treatment with selective immunosuppressive therapy (SIT: infliximab and vedolizumab), between 01/2016 and 02/2022 at MD Anderson Cancer Center. Patient demographics, clinical characteristics, and IMDC data were collected and analyzed. Results: Our sample of 128 patients had a median age of 67 years; most were white (89.8%); and male (65.6%). Prior to development of IMDC, 15 (11.7%) were initially treated with anti-CTLA-4, 42 (32.8%) with anti-PD-1 or PD-L1, and 71 (55.5%) with a combination of both. We found higher CRP level was associated with higher CTCAE grade of clinical symptoms such as diarrhea (p=0.015), colitis (p=0.013), and endoscopic findings (p=0.016). While CRP levels decreased after IMDC treatment, there was no significant association between CRP levels with clinical remission, endoscopic remission or histologic remission. There also was no significant correlation between CRP level and recurrence of IMDC, or with fecal calprotectin levels. Conclusion: CRP level may be useful to assess initial severity of IMDC, including grade of diarrhea and colitis and degree of endoscopic inflammation. However, CRP is not a robust surrogate biomarker for assessing treatment response or disease recurrence. Despite the reduction of CRP levels observed following IMDC treatment, this finding might be nonspecific and potentially confounded by concurrent clinical factors, such as underlying malignancy, other inflammatory processes, and systemic anti-cancer therapy. Further studies of the role of CRP are warranted in patients with cancer and IMDC.
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Affiliation(s)
- Cynthia Liu
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Malek Shatila
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Antony Mathew
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, TX, USA
| | - Antonio Pizuorno Machado
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, TX, USA
| | - Austin Thomas
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, TX, USA
| | - Hao Chi Zhang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anusha S. Thomas
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Faleck
- Gastroenterology, Hepatology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pauline Funchain
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica Philpott
- Center for Inflammatory Bowel Disease, Cleveland Clinic, Cleveland, OH, USA
| | - Petros Grivas
- Department of Medicine, Division of Oncology, University of Washington, Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Michel Obeid
- Centre Hospitalier Universitaire Vaudois, Department of Medicine, Service of Immunology and Allergy, Lausanne, Switzerland
| | - Franck Carbonnel
- Gastroenterology Department, Université Paris Saclay 11, Le Kremlin-Bicêtre, France
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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14
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Frade-Sosa B, Chacur CA, Augé JM, Ponce A, Sarmiento-Monroy JC, Azuaga AB, Sapena N, Ramírez J, Ruiz-Esquide V, Morlà R, Farietta S, Corzo P, Cañete JD, Sanmartí R, Gómez-Puerta JA. Calprotectin in Patients with Rheumatic Immunomediated Adverse Effects Induced by Checkpoints Inhibitors. Cancers (Basel) 2023; 15:cancers15112984. [PMID: 37296947 DOI: 10.3390/cancers15112984] [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: 05/09/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND this is an exploratory study to evaluate calprotectin serum levels in patients with rheumatic immune-related adverse events (irAEs) induced by immune checkpoint inhibitor (ICI) treatment. METHODS this is a retrospective observational study including patients with irAEs rheumatic syndromes. We compared the calprotectin levels to those in a control group of patients with RA and with a control group of healthy individuals. Additionally, we included a control group of patients treated with ICI but without irAEs to check calprotectin levels. We also analysed the performance of calprotectin for the identification of active rheumatic disease using receiver operating characteristic curves (ROC). RESULTS 18 patients with rheumatic irAEs were compared to a control group of 128 RA patients and another group of 29 healthy donors. The mean calprotectin level in the irAE group was 5.15 μg/mL, which was higher than the levels in both the RA group (3.19 μg/mL) and the healthy group (3.81 μg/mL) (cut-off 2 μg/mL). Additionally, 8 oncology patients without irAEs were included. In this group, calprotectin levels were similar to those of the healthy controls. In patients with active inflammation, the calprotectin levels in the irAE group were significantly higher (8.43 μg/mL) compared to the RA group (3.94 μg/mL). ROC curve analysis showed that calprotectin had a very good discriminatory capacity to identify inflammatory activity in patients with rheumatic irAEs (AUC of 0.864). CONCLUSIONS the results suggest that calprotectin may serve as a marker of inflammatory activity in patients with rheumatic irAEs induced by treatment with ICIs.
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Affiliation(s)
- Beatriz Frade-Sosa
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Chafik Alejandro Chacur
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Josep M Augé
- Department of Biochemistry and Molecular Genetics (CDB), Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Andrés Ponce
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Juan C Sarmiento-Monroy
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Ana Belén Azuaga
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Nuria Sapena
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Julio Ramírez
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Virginia Ruiz-Esquide
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Rosa Morlà
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Sandra Farietta
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Patricia Corzo
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Juan D Cañete
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Raimon Sanmartí
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - José A Gómez-Puerta
- Department of Rheumatology, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
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15
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Özdemir BC, Espinosa da Silva C, Arangalage D, Monney P, Guler SA, Huynh-Do U, Stirnimann G, Possamai L, Trepp R, Hoepner R, Salmen A, Gerard CL, Hruz P, Christ L, Rothschild SI. Multidisciplinary recommendations for essential baseline functional and laboratory tests to facilitate early diagnosis and management of immune-related adverse events among cancer patients. Cancer Immunol Immunother 2023:10.1007/s00262-023-03436-0. [PMID: 37017694 DOI: 10.1007/s00262-023-03436-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/22/2023] [Indexed: 04/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have fundamentally changed the treatment landscape of various cancers. While ICI treatments result in improved survival, quality of life and are cost-effective, the majority of patients experience at least one immune-related adverse event (irAE). Many of these side effects cause little discomfort or are asymptomatic; however, irAEs can affect any organ and are potentially life-threatening. Consequently, early diagnosis and appropriate treatment of irAEs are critical for optimizing long-term outcomes and quality of life in affected patients. Some irAEs are diagnosed according to typical symptoms, others by abnormal findings from diagnostic tests. While there are various guidelines addressing the management of irAEs, recommendations for the early recognition of irAEs as well as the optimal extent and frequency of laboratory tests are mostly lacking. In clinical practice, blood sampling is usually performed before each ICI administration (i.e., every 2-3 weeks), often for several months, representing a burden for patients as well as health care systems. In this report, we propose essential laboratory and functional tests to improve the early detection and management of irAEs and in cancer patients treated with ICIs. These multidisciplinary expert recommendations regarding essential laboratory and functional tests can be used to identify possible irAEs at an early time point, initiate appropriate interventions to improve patient outcomes, and reduce the burden of blood sampling during ICI treatment.
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Affiliation(s)
- Berna C Özdemir
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Cristina Espinosa da Silva
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, USA
| | - Dimitri Arangalage
- Department of Cardiology, INSERM U1148, Bichat Hospital, University of Paris, Paris, France
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Sabina A Guler
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lucia Possamai
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Roman Trepp
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Camille L Gerard
- Department of Oncology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
- The Francis Crick Institute, London, UK
| | - Petr Hruz
- Department of Gastroenterology, University Hospital Basel, Basel, Switzerland
| | - Lisa Christ
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sacha I Rothschild
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department Internal Medicine, Center for Oncology and Hematology, Cantonal Hospital Baden, Baden, Switzerland
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Les I, Martínez M, Pérez-Francisco I, Cabero M, Teijeira L, Arrazubi V, Torrego N, Campillo-Calatayud A, Elejalde I, Kochan G, Escors D. Predictive Biomarkers for Checkpoint Inhibitor Immune-Related Adverse Events. Cancers (Basel) 2023; 15:cancers15051629. [PMID: 36900420 PMCID: PMC10000735 DOI: 10.3390/cancers15051629] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023] Open
Abstract
Immune-checkpoint inhibitors (ICIs) are antagonists of inhibitory receptors in the immune system, such as the cytotoxic T-lymphocyte-associated antigen-4, the programmed cell death protein-1 and its ligand PD-L1, and they are increasingly used in cancer treatment. By blocking certain suppressive pathways, ICIs promote T-cell activation and antitumor activity but may induce so-called immune-related adverse events (irAEs), which mimic traditional autoimmune disorders. With the approval of more ICIs, irAE prediction has become a key factor in improving patient survival and quality of life. Several biomarkers have been described as potential irAE predictors, some of them are already available for clinical use and others are under development; examples include circulating blood cell counts and ratios, T-cell expansion and diversification, cytokines, autoantibodies and autoantigens, serum and other biological fluid proteins, human leucocyte antigen genotypes, genetic variations and gene profiles, microRNAs, and the gastrointestinal microbiome. Nevertheless, it is difficult to generalize the application of irAE biomarkers based on the current evidence because most studies have been retrospective, time-limited and restricted to a specific type of cancer, irAE or ICI. Long-term prospective cohorts and real-life studies are needed to assess the predictive capacity of different potential irAE biomarkers, regardless of the ICI type, organ involved or cancer site.
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Affiliation(s)
- Iñigo Les
- Internal Medicine Department, Navarre University Hospital, 31008 Pamplona, Spain
- Autoimmune Diseases Unit, Internal Medicine Department, Navarre University Hospital, 31008 Pamplona, Spain
- Inflammatory and Immune-Mediated Diseases Group, Instituto de Investigación Sanitaria de Navarra (IdISNA), Navarrabiomed-Public University of Navarre, 31008 Pamplona, Spain
- Correspondence: (I.L.); (D.E.); Tel.: +34-84-842-9516 (I.L.)
| | - Mireia Martínez
- Osakidetza Basque Health Service, Department of Medical Oncology, Araba University Hospital, 01009 Vitoria-Gasteiz, Spain
- Lung Cancer Research Group, Bioaraba Health Research Institute, 01006 Vitoria-Gasteiz, Spain
| | - Inés Pérez-Francisco
- Breast Cancer Research Group, Bioaraba Health Research Institute, 01006 Vitoria-Gasteiz, Spain
| | - María Cabero
- Clinical Trials Platform, Bioaraba Health Research Institute, 01006 Vitoria-Gasteiz, Spain
| | - Lucía Teijeira
- Medical Oncology Department, Navarre University Hospital, 31008 Pamplona, Spain
| | - Virginia Arrazubi
- Medical Oncology Department, Navarre University Hospital, 31008 Pamplona, Spain
| | - Nuria Torrego
- Osakidetza Basque Health Service, Department of Medical Oncology, Araba University Hospital, 01009 Vitoria-Gasteiz, Spain
- Lung Cancer Research Group, Bioaraba Health Research Institute, 01006 Vitoria-Gasteiz, Spain
| | - Ana Campillo-Calatayud
- Inflammatory and Immune-Mediated Diseases Group, Instituto de Investigación Sanitaria de Navarra (IdISNA), Navarrabiomed-Public University of Navarre, 31008 Pamplona, Spain
| | - Iñaki Elejalde
- Internal Medicine Department, Navarre University Hospital, 31008 Pamplona, Spain
- Autoimmune Diseases Unit, Internal Medicine Department, Navarre University Hospital, 31008 Pamplona, Spain
- Inflammatory and Immune-Mediated Diseases Group, Instituto de Investigación Sanitaria de Navarra (IdISNA), Navarrabiomed-Public University of Navarre, 31008 Pamplona, Spain
| | - Grazyna Kochan
- Oncoimmunology Group, Instituto de Investigación Sanitaria de Navarra (IdISNA), Navarrabiomed-Public University of Navarre, 31008 Pamplona, Spain
| | - David Escors
- Oncoimmunology Group, Instituto de Investigación Sanitaria de Navarra (IdISNA), Navarrabiomed-Public University of Navarre, 31008 Pamplona, Spain
- Correspondence: (I.L.); (D.E.); Tel.: +34-84-842-9516 (I.L.)
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España Fernandez S, Sun C, Solé-Blanch C, Boada A, Martínez-Cardús A, Manzano JL. Immunotherapy Resumption/Rechallenge in Melanoma Patients after Toxicity: Do We Have Another Chance? Pharmaceutics 2023; 15:pharmaceutics15030823. [PMID: 36986683 PMCID: PMC10052939 DOI: 10.3390/pharmaceutics15030823] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction: Immune checkpoint inhibitors (ICIs) have radically changed the prognosis of several neoplasias, among them metastatic melanoma. In the past decade, some of these new drugs have appeared together with a new toxicity spectrum previously unknown to clinicians, until now. A common situation in daily practice is that a patient experiences toxicity due to this type of drug and we need to resume or rechallenge treatment after resolving the adverse event. Methods: A PubMed literature review was carried out. Results: The published data regarding the resumption or rechallenge of ICI treatment in melanoma patients is scarce and heterogeneous. Depending on the study reviewed, the recurrence incidence of grade 3–4 immune-related adverse events (irAEs) ranged from 18% to 82%. Conclusion: It is possible to resume or rechallenge, but each patient should be evaluated by a multidisciplinary team for close monitoring and assessment of the risk/benefit ratio before initiating treatment.
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Affiliation(s)
- Sofia España Fernandez
- Medical Oncology Department, Catalan Institute of Oncology Badalona, 08916 Badalona, Spain
- Badalona-Applied Research Group in Oncology (B-ARGO), IGTP (Health Research Institute Germans Trias i Pujol), 08916 Badalona, Spain
- Correspondence:
| | - Chen Sun
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450014, China
| | - Carme Solé-Blanch
- Badalona-Applied Research Group in Oncology (B-ARGO), IGTP (Health Research Institute Germans Trias i Pujol), 08916 Badalona, Spain
| | - Aram Boada
- Dermatology Department, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Spain
| | - Anna Martínez-Cardús
- Badalona-Applied Research Group in Oncology (B-ARGO), IGTP (Health Research Institute Germans Trias i Pujol), 08916 Badalona, Spain
| | - José Luis Manzano
- Medical Oncology Department, Catalan Institute of Oncology Badalona, 08916 Badalona, Spain
- Badalona-Applied Research Group in Oncology (B-ARGO), IGTP (Health Research Institute Germans Trias i Pujol), 08916 Badalona, Spain
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Wang Y, Jenq RR, Wargo JA, Watowich SS. Microbiome influencers of checkpoint blockade-associated toxicity. J Exp Med 2023; 220:213796. [PMID: 36622383 PMCID: PMC9836236 DOI: 10.1084/jem.20220948] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 01/10/2023] Open
Abstract
Immunotherapy has greatly improved cancer outcomes, yet variability in response and off-target tissue damage can occur with these treatments, including immune checkpoint inhibitors (ICIs). Multiple lines of evidence indicate the host microbiome influences ICI response and risk of immune-related adverse events (irAEs). As the microbiome is modifiable, these advances indicate the potential to manipulate microbiome components to increase ICI success. We discuss microbiome features associated with ICI response, with focus on bacterial taxa and potential immune mechanisms involved in irAEs, and the overall goal of driving novel approaches to manipulate the microbiome to improve ICI efficacy while avoiding irAE risk.
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Affiliation(s)
- Yinghong Wang
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert R. Jenq
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA,Platform for Innovative Microbiome and Translational Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer A. Wargo
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA,Platform for Innovative Microbiome and Translational Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephanie S. Watowich
- Platform for Innovative Microbiome and Translational Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA,Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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19
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Check this out: treatment paradigms in immune-checkpoint inhibitor colitis. Curr Opin Gastroenterol 2023; 39:43-49. [PMID: 36504035 DOI: 10.1097/mog.0000000000000892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICI) have become a pillar of cancer therapy for many people around the world. However, up to two-thirds of all patients undergoing ICI therapy will have immune-related adverse events (irAEs), including immune-checkpoint inhibitor colitis (ICIC). This review summarizes the most valuable and currently available information about the mechanism, diagnosis, and management of ICIC. RECENT FINDINGS Recent findings include several developments on the leading theories for the mechanisms of ICIC such as the role of the gut microbiome. New emerging therapy strategies include tocilizumab, ustekinumab, mycophenolate mofetil, and calcineurin inhibitors. SUMMARY The occurrence of irAEs remains a limiting factor for the use of immunotherapy in cancer treatment. Prompt diagnosis of ICIC with endoscopy and histologic confirmation can lead to early utilization of known effective treatments such as corticosteroids, infliximab, vedolizumab, and other emerging therapy strategies. We summarize the key points of this review article in our abstract video, Supplemental Digital Content 1, http://links.lww.com/COG/A44.
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Saji A, Chopra M, Jacob J, Altan M, Alhalabi O, Shah AY, Qiao W, Wang Y, Thomas A. Implementing an immunotherapy toxicity (IOTOX) GI service improves outcomes in patients with immune-mediated diarrhea and colitis. J Cancer Res Clin Oncol 2022. [PMID: 36585982 DOI: 10.1007/s00432-022-04545-6.10.1007/s00432-022-04545-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
PURPOSE Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but can lead to GI toxicity, termed immune-mediated diarrhea and colitis (IMDC). Standardization of IMDC management and early GI consultation is imperative to control symptoms and prevent delays in cancer care. Therefore, we implemented an inpatient algorithm and a focused IOTOX GI service to measure outcomes. METHODS Patients who received ICIs and were hospitalized with severe IMDC were grouped into a pre-interventional cohort in 2017, followed by implementation of the standardized algorithm in 2018, and then a post-interventional cohort of patients in 2019. Clinical data and patient outcomes were compared using univariate and multivariate analysis to determine the morbidity, and overall survival. RESULTS Our sample comprised 126 hospitalized patients with IMDC, with 59 patients in the pre-interventional 2017 cohort, and 67 patients in the post-interventional 2019 cohort. We found no significant differences in the clinical severity of IMDC symptoms between the two cohorts (p = 1.03) or median time from ICI exposure to development of IMDC (p = 0.495, respectively). After implementing the standardized algorithm, we observed higher rates of GI consultation (p < 0.001) in the post-treatment group. Patients in the post-treatment cohort showed decreased time to clinical remission (4 vs 10 days, p = 0.046), higher rate of GI follow-up after hospital discharge (p = 0.038), fewer hospital re-admissions (p = 0.002), and significantly fewer recurrences of IMDC symptoms (p = 0.002). Overall survival was significantly higher for at least 2 years in patients who followed with GI post-discharge compared to those without follow-up (p = 0.003). CONCLUSION Prompt GI consultation and monitoring of IMDC using a regimented approach can provide efficacious management, decrease time to clinical remission of symptoms, decrease re-admissions to the hospital, and improve overall patient outcomes.
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Affiliation(s)
- Alice Saji
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX, 77079, USA
| | - Maneera Chopra
- Division of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jake Jacob
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mehmet Altan
- Department of Thoracic, Head and Neck Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX, USA
| | - Omar Alhalabi
- Department of Genitourinary Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX, USA
| | - Amishi Yogesh Shah
- Department of Genitourinary Medical Oncology, The University of M.D. Anderson Cancer Center, Houston, TX, USA
| | - Wei Qiao
- Department of Biostatistics, The University of M.D. Anderson Cancer Center, Houston, TX, USA
| | - Yinghong Wang
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX, 77079, USA
| | - Anusha Thomas
- Department of Gastroenterology Hepatology and Nutrition, Unit 1466, Division of Internal Medicine, The University of M.D. Anderson Cancer Center, 13900 Katy Freeway, Houston, TX, 77079, USA.
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Saha A, Dreyfuss I, Sarfraz H, Friedman M, Markowitz J. Dietary Considerations for Inflammatory Bowel Disease Are Useful for Treatment of Checkpoint Inhibitor-Induced Colitis. Cancers (Basel) 2022; 15:84. [PMID: 36612082 PMCID: PMC9817715 DOI: 10.3390/cancers15010084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022] Open
Abstract
Checkpoint molecules are cell surface receptors on immune cells that mitigate excessive immune responses, but they have increased expression levels in cancer to facilitate immune escape. Checkpoint blockade therapies (e.g., anti-PD-1, anti-CTLA-4, and anti-LAG-3 therapy, among others) have been developed for multiple cancers. Colitis associated with checkpoint blockade therapy has pathophysiological similarities to inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. Current therapeutic guidelines for checkpoint blockade-induced colitis include corticosteroids and, if the patient is refractory to steroids, immunomodulating antibodies, such as anti-TNF and anti-integrin agents. Interestingly, immunomodulatory molecules, such as TNFα, are upregulated in both IBD and checkpoint-mediated colitis. The inflammatory colitis toxicity symptoms from checkpoint blockade are similar to clinical symptoms experienced by patients with IBD. The pathophysiologic, dietary, and genetic factors associated with IBD will be reviewed. We will then explain how the principles developed for the treatment of IBD can be applied to patients experiencing inflammatory bowel toxicity secondary to checkpoint blockade.
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Affiliation(s)
- Aditi Saha
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Isabella Dreyfuss
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Humaira Sarfraz
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Mark Friedman
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Joseph Markowitz
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida School of Medicine, Tampa, FL 33612, USA
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22
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Immune checkpoint Inhibitor–Induced diarrhea and Colitis: Incidence and Management. A systematic review and Meta-analysis. Cancer Treat Rev 2022; 109:102440. [DOI: 10.1016/j.ctrv.2022.102440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 11/22/2022]
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23
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Mesalamine and cholestyramine for immune checkpoint inhibitor-mediated diarrhea and colitis. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04116-9. [PMID: 35972690 DOI: 10.1007/s00432-022-04116-9] [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: 05/03/2022] [Accepted: 06/06/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Immune checkpoint inhibitors (ICI) are effective against various malignancies. However, adverse events including diarrhea and colitis can lead to significant morbidity and mortality. Recommendations for the management of ICI mediated diarrhea and colitis include steroids and biologics. Given their associated risks, this study evaluated the role of the non-immunosuppressive agents, mesalamine and or cholestyramine. METHODS This is a retrospective, descriptive, single-center study of adults who developed ICI diarrhea and colitis between 2010 and 2020 at MD Anderson Cancer Center. Clinical data and outcomes were compared between those treated with the non-immunosuppressive therapies mesalamine and/or cholestyramine alone versus those who received additional immunosuppression with steroids and biologics. RESULTS Our sample comprised 66 patients wherein, the mean age was 63 years, 71% were males, and 97% had stage III/IV cancers. Fourteen patients were treated successfully with non-immunosuppressive therapy. They had grade 1-3 diarrhea and 1-2 colitis with no difference in the rate of histologic colitis compared to those who received immunosuppressive therapy. They had less CTLA-4 inhibitor-based therapy (36% vs. 73%, p = 0.034), delayed onset of symptoms (159 vs. 64 days, p = 0.011), lower fecal calprotectin levels (56 vs. 234, p = 0.012) and were more likely to resume ICI therapy (64% vs. 25%, p = 0.006). CONCLUSION Mesalamine and/or cholestyramine may be effective for mild ICI diarrhea and colitis among patients with delayed symptom onset with lower colonic inflammatory burden. Prospective studies randomizing patients with mild colitis between mesalamine/cholestyramine and immunosuppressive treatment are warranted to assess their efficacy and safety.
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Chen M, Liu M, Li C, Peng S, Li Y, Xu X, Sun M, Sun X. Fecal Microbiota Transplantation Effectively Cures a Patient With Severe Bleeding Immune Checkpoint Inhibitor-Associated Colitis and a Short Review. Front Oncol 2022; 12:913217. [PMID: 35756645 PMCID: PMC9229182 DOI: 10.3389/fonc.2022.913217] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have opened up a new way for tumor therapy but simultaneously led to the occurrence of immune-related adverse events. We report a case of successful treatment of PD-1 inhibitor-associated colitis with fecal microbiota transplantation (FMT). The patient was a palatal malignant melanoma who developed diarrhea and hematochezia accompanied by fever, gastrointestinal bleeding, and infection after the third treatment with PD-1 (Toripalimab). The patient received general treatment unsuccessful, corticosteroid therapy after initial success but rapid loss of response, and finally successful treatment after fecal microbiota transplantation.
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Affiliation(s)
- Minmin Chen
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Mengyuan Liu
- Department of Gastrointestinal Endoscopy, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Chenyan Li
- Department of Endocrinology and Metabolism, First Hospital of China Medical University, Shenyang, China
| | - Shiqiao Peng
- Department of Endocrinology and Metabolism, First Hospital of China Medical University, Shenyang, China
| | - Yiling Li
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiuying Xu
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Mingjun Sun
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, China.,Department of Gastrointestinal Endoscopy, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xuren Sun
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, China
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Chennamadhavuni A, Abushahin L, Jin N, Presley CJ, Manne A. Risk Factors and Biomarkers for Immune-Related Adverse Events: A Practical Guide to Identifying High-Risk Patients and Rechallenging Immune Checkpoint Inhibitors. Front Immunol 2022; 13:779691. [PMID: 35558065 PMCID: PMC9086893 DOI: 10.3389/fimmu.2022.779691] [Citation(s) in RCA: 120] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/31/2022] [Indexed: 12/19/2022] Open
Abstract
Immune-related adverse events (irAEs) are a range of complications associated with the use of immune-checkpoint inhibitors (ICIs). Two major classes of ICIs widely used are Cytotoxic T-Lymphocyte Antigen 4 (CTLA4) and Programmed Cell death-1 (PD-1)/Programmed death-ligand 1 (PD-L1) inhibitors. High-grade irAEs are life-threatening and often cause a severe decline in performance status in such that patients do not qualify for any further anticancer treatments. It is difficult to generalize the evidence in the current literature on risk factors or biomarkers for the entire class of ICIs as the studies so far are either disease-specific (e.g., lung cancer or melanoma) or ICI agent-specific (e.g., pembrolizumab, ipilimumab) or irAE-specific (e.g., pneumonitis or gastritis). In this review, risk factors and biomarkers to consider before initiating or monitoring ICI are listed with a practical purpose in day-to-day practice. Risk factors are grouped into demographics and social history, medical history, and medication history, tumor-specific and agent-specific risk factors. A higher risk of irAE is associated with age <60 years, high body mass index, women on CTLA4 and men on PD-1/PD-L1 agents, and chronic smokers. Patients with significant kidney (Stage IV-V), cardiac (heart failure, coronary artery disease, myocardial infarction, hypertension), and lung (asthma, pulmonary fibrosis, and chronic obstructive pulmonary disease) are at a higher risk of respective organ-specific irAEs. Pre-existing autoimmune disease and chronic use of certain drugs (proton pump inhibitors, diuretics, anti-inflammatory drugs) also increase the irAE-risk. Biomarkers are categorized into circulating blood counts, cytokines, autoantibodies, HLA genotypes, microRNA, gene expression profiling, and serum proteins. The blood counts and certain protein markers (albumin and thyroid-stimulating hormone) are readily accessible in current practice. High neutrophil-lymphocyte ratio, eosinophil/monocyte/lymphocyte counts; TSH and troponins at diagnosis and drop in the white count and lymphocyte count can predict irAE. Other biomarkers with limited evidence are cytokines, autoantibodies, HLA genotypes, microRNA, and gene expression profiling. With fast-expanding approvals for ICIs in various cancer types, knowledge on risk factors and biomarkers can help providers assess the irAE-risk of their patients. Prospective disease and agent-specific studies are needed to provide further insight on this essential aspect of ICI therapy.
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Affiliation(s)
- Adithya Chennamadhavuni
- University of Iowa Hospitals and Clinics, Holden Comprehensive Cancer Center, Iowa City, IA, United States
| | - Laith Abushahin
- Department of Internal Medicine, Division of Medical Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Ning Jin
- Department of Internal Medicine, Division of Medical Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Carolyn J Presley
- Department of Internal Medicine, Division of Medical Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Ashish Manne
- Department of Internal Medicine, Division of Medical Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
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Ma C, Pai RK, Schaeffer DF, Krell J, Guizzetti L, McFarlane SC, MacDonald JK, Choi WT, Feakins RM, Kirsch R, Lauwers GY, Pai RK, Rosty C, Srivastava A, Walsh JC, Feagan BG, Jairath V. Recommendations for standardizing biopsy acquisition and histological assessment of immune checkpoint inhibitor-associated colitis. J Immunother Cancer 2022; 10:jitc-2022-004560. [PMID: 35296560 PMCID: PMC8928359 DOI: 10.1136/jitc-2022-004560] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/13/2022] Open
Abstract
Immune checkpoint inhibitor-associated colitis (ICIC) affects approximately 15% of cancer patients treated with immunotherapy. Although histological evaluation is potentially valuable for both the diagnosis of ICIC and evaluation of disease activity, use in clinical practice is heterogeneous. We aimed to develop expert recommendations to standardize histological assessment of disease activity in patients with ICIC. Using the modified Research and Development/University of California Los Angeles (RAND/UCLA) appropriateness methodology, an international panel of 11 pathologists rated the appropriateness of 99 statements on a 9-point Likert scale during two rounds of anonymous voting. Results were discussed between rounds using moderated videoconferences. There are currently no disease-specific instruments for assessing histological features of ICIC. The panel considered that colonoscopy with at least three biopsies per segment from a total of at least five segments, including both endoscopically normal and inflamed areas, was appropriate for tissue acquisition. They agreed that biopsies should be oriented such that the long axis of the colonic crypts is visualized and should be stained with hematoxylin and eosin. Histological items that the panel voted were appropriate to evaluate in ICIC included the degree of structural/architectural change, chronic inflammatory infiltrate, lamina propria and intraepithelial neutrophils, crypt abscesses and destruction, erosions/ulcerations, apoptosis, surface intraepithelial lymphocytosis, and subepithelial collagen thickness. The appropriateness of routine immunohistochemistry was uncertain. These expert recommendations will help standardize assessment of histological activity in patients with ICIC. The panel also identified the development and validation of an ICIC-specific histological index as a research priority.
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Affiliation(s)
- Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada .,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alimentiv Inc, London, Ontario, Canada
| | - Rish K Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - David F Schaeffer
- Division of Anatomic Pathology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jonathan Krell
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | | | | | | | - Won-Tak Choi
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Roger M Feakins
- Department of Histopathology, Royal Free Hospital, London, UK
| | - Richard Kirsch
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gregory Y Lauwers
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.,Departments of Pathology and Oncologic Sciences, University of South Florida, Tampa, Florida, USA
| | - Reetesh K Pai
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christophe Rosty
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Envoi Specialist Pathologists, Brisbane, Queensland, Australia.,Department of Pathology, University of Melbourne, Melbourne, Victoria, Australia
| | - Amitabh Srivastava
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joanna C Walsh
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Division of Gastroenterology, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Division of Gastroenterology, Schulich School of Medicine, Western University, London, Ontario, Canada
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De Silva S, Trieu H, Rajan A, Liang Y, Lin JL, Kidambi TD. Flexible sigmoidoscopy may be sufficient for initial evaluation of suspected immunotherapy-mediated colitis: A cross-sectional study. J Gastroenterol Hepatol 2022; 37:284-290. [PMID: 34547818 DOI: 10.1111/jgh.15691] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/31/2021] [Accepted: 09/19/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Immune checkpoint inhibitors (ICIs) have shown promise in treating a variety of cancers. Their increased use coincides with increased incidence of immunotherapy-mediated colitis (IMC), a common adverse effect. Optimal strategy for endoscopic evaluation of IMC (full colonoscopy or flexible sigmoidoscopy) is not well-defined. METHODS Retrospective review of all patients at City of Hope referred to gastroenterology for evaluation of IMC due to gastrointestinal symptoms was performed. Patients with an existing histologic diagnosis of IMC established at an outside hospital or a diagnosis of infectious or chronic colitis were excluded. RESULTS We identified 51 symptomatic patients on ICIs prompting evaluation for IMC with colonoscopy (47/51) or flexible sigmoidoscopy (4/51). All distal rectosigmoid biopsies during flexible sigmoidoscopy demonstrated histologic evidence of IMC. In full colonoscopy, IMC was either present in all segments of colon simultaneously (35/47) or absent from all segments (12/47). No isolated proximal colonic biopsies demonstrated IMC. Endoscopically normal mucosa demonstrated histologic evidence of IMC up to 68.6% of the time. Endoscopically abnormal right, transverse, and left colon had low sensitivity (35.3%, 34.3%, and 41.7%, respectively) and high specificity (100.0%, 100.0%, and 91.7%, respectively) for histological presence of IMC. CONCLUSIONS Distal colon biopsies in patients on ICI therapy with diarrhea and suspected IMC were sufficient for diagnosing IMC in our cohort. Further, we found histologic evidence of IMC in biopsies taken from normal-appearing mucosa in a number of patients, suggesting that a normal endoscopic appearance does not preclude the presence of IMC and biopsies should be taken from both normal and abnormal-appearing mucosa.
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Affiliation(s)
- Sadie De Silva
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA.,Department of Medicine, Temecula Valley Hospital, Temecula, California, USA
| | - Harry Trieu
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anand Rajan
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA.,Department of Medicine, Olive View Medical Center, Los Angeles, California, USA
| | - Yu Liang
- Department of Pathology, City of Hope Medical Center, Duarte, California, USA
| | - James L Lin
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA
| | - Trilokesh D Kidambi
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA
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Schneider BJ, Lacchetti C, Bollin K. Management of the Top 10 Most Common Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy. JCO Oncol Pract 2022; 18:431-444. [DOI: 10.1200/op.21.00776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Thomas AS, Wang Y. Immunotherapy-Mediated Luminal Gastrointestinal Toxicities. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1342:331-337. [PMID: 34972972 DOI: 10.1007/978-3-030-79308-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The advent of immune checkpoint blockade and its application in the management of advanced malignancies has revolutionized cancer therapies, outcomes, and survival. As beneficial as these class of drugs have been proven to be, their use is not devoid of complications, viz., immune-related adverse events (irAEs). The gastrointestinal (GI) tract is the second most frequently affected organ system, and toxicities may vary in severity from mild disease to aggressive life-threatening clinical presentations. Timely diagnosis that incorporates clinical, biochemical, imaging, endoscopic, and histologic evaluation is imperative for efficacious management of this disease process to ensure good outcomes. Management varies depending on severity and can comprise supportive care in milder disease patterns as well as vigorous immunosuppression in aggressive cases.
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Affiliation(s)
- Anusha S Thomas
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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30
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Tang L, Wang J, Lin N, Zhou Y, He W, Liu J, Ma X. Immune Checkpoint Inhibitor-Associated Colitis: From Mechanism to Management. Front Immunol 2021; 12:800879. [PMID: 34992611 PMCID: PMC8724248 DOI: 10.3389/fimmu.2021.800879] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 11/29/2021] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs), as one of the innovative types of immunotherapies, including programmed cell death-1 (PD-1), programmed cell death-ligand 1 (PD-L1), and cytotoxic T lymphocyte antigen 4 (CTLA-4) inhibitors, have obtained unprecedented benefit in multiple malignancies. However, the immune response activation in the body organs could arise immune-related adverse events (irAEs). Checkpoint inhibitor colitis (CIC) is the most widely reported irAEs. However, some obscure problems, such as the mechanism concerning gut microbiota, the confusing differential diagnosis with inflammatory bowel disease (IBD), the optimal steroid schedule, the reintroduction of ICIs, and the controversial prognosis features, influence the deep understanding and precise diagnosis and management of CIC. Herein, we based on these problems and comprehensively summarized the relevant studies of CIC in patients with NSCLC, further discussing the future research direction of this specific pattern of irAEs.
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Affiliation(s)
- Liansha Tang
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jialing Wang
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Nan Lin
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yuwen Zhou
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenbo He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiyan Liu
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xuelei Ma
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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31
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Schneider BJ, Naidoo J, Santomasso BD, Lacchetti C, Adkins S, Anadkat M, Atkins MB, Brassil KJ, Caterino JM, Chau I, Davies MJ, Ernstoff MS, Fecher L, Ghosh M, Jaiyesimi I, Mammen JS, Naing A, Nastoupil LJ, Phillips T, Porter LD, Reichner CA, Seigel C, Song JM, Spira A, Suarez-Almazor M, Swami U, Thompson JA, Vikas P, Wang Y, Weber JS, Funchain P, Bollin K. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update. J Clin Oncol 2021; 39:4073-4126. [PMID: 34724392 DOI: 10.1200/jco.21.01440] [Citation(s) in RCA: 624] [Impact Index Per Article: 208.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with immune checkpoint inhibitor (ICPi) therapy. METHODS A multidisciplinary panel of medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to update the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 through 2021. RESULTS A total of 175 studies met the eligibility criteria of the systematic review and were pertinent to the development of the recommendations. Because of the paucity of high-quality evidence, recommendations are based on expert consensus. RECOMMENDATIONS Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to the organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, except for some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert ≤ grade 1. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids. Corticosteroids should be tapered over the course of at least 4-6 weeks. Some refractory cases may require other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, except for endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
| | - Jarushka Naidoo
- Beaumont Hospital, Dublin, Ireland.,Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | | | | | | | | | | | - Ian Chau
- Royal Marsden Hospital and Institute of Cancer Research, London & Surrey, Sutton, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Umang Swami
- Huntsman Cancer Institute-University of Utah, Salt Lake City, UT
| | - John A Thompson
- Seattle Cancer Care Alliance, University of Washington/Fred Hutchinson, Seattle, WA
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32
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Westdorp H, Sweep MWD, Gorris MAJ, Hoentjen F, Boers-Sonderen MJ, van der Post RS, van den Heuvel MM, Piet B, Boleij A, Bloemendal HJ, de Vries IJM. Mechanisms of Immune Checkpoint Inhibitor-Mediated Colitis. Front Immunol 2021; 12:768957. [PMID: 34777387 PMCID: PMC8586074 DOI: 10.3389/fimmu.2021.768957] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/11/2021] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have provided tremendous clinical benefit in several cancer types. However, systemic activation of the immune system also leads to several immune-related adverse events. Of these, ICI-mediated colitis (IMC) occurs frequently and is the one with the highest absolute fatality. To improve current treatment strategies, it is important to understand the cellular mechanisms that induce this form of colitis. In this review, we discuss important pathways that are altered in IMC in mouse models and in human colon biopsy samples. This reveals a complex interplay between several types of immune cells and the gut microbiome. In addition to a mechanistic understanding, patients at risk should be identifiable before ICI therapy. Here we propose to focus on T-cell subsets that interact with bacteria after inducing epithelial damage. Especially, intestinal resident immune cells are of interest. This may lead to a better understanding of IMC and provides opportunities for prevention and management.
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Affiliation(s)
- Harm Westdorp
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mark W. D. Sweep
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mark A. J. Gorris
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Oncode Institute, Nijmegen, Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology, Radboud University Medical Centre, Nijmegen, Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | | | - Rachel S. van der Post
- Department of Pathology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Berber Piet
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Pulmonary Diseases, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Annemarie Boleij
- Department of Pathology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Haiko J. Bloemendal
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - I. Jolanda M. de Vries
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
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33
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Hashash JG, Francis FF, Farraye FA. Diagnosis and Management of Immune Checkpoint Inhibitor Colitis. Gastroenterol Hepatol (N Y) 2021; 17:358-366. [PMID: 34602898 PMCID: PMC8475264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Increased use of immune checkpoint inhibitors (ICIs) has created a rise in immune-related adverse events (irAEs), which may affect any system in the body. Gastrointestinal (GI) irAEs such as immune-mediated colitis are common, occurring in 35% to 50% of patients receiving ICIs. GI irAEs usually develop 6 to 8 weeks after ICI initiation and can involve any part of the GI system. Patients with immune-mediated colitis are categorized into 1 of 5 grades based on the National Cancer Institute's Common Terminology Criteria for Adverse Events, which also guide treatment decisions. An infectious cause for the diarrhea should be excluded in all patients. Patients with grade 1 symptoms are managed conservatively. Patients with grade 2 or higher symptoms should undergo a colonoscopy and are treated with systemic corticosteroids and, depending on their response, biologic therapy. The aim of this article is to review the diagnosis and management of patients with immune-mediated colitis, which should be identified early and addressed promptly to avoid detrimental outcomes.
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Affiliation(s)
- Jana G. Hashash
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon
| | - Fadi F. Francis
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon
| | - Francis A. Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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