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Rossi S, Farina A, Malvaso A, Dinoto A, Fionda L, Cornacchini S, Florean I, Zuliani L, Garibaldi M, Lauletta A, Baccari F, Zenesini C, Rinaldi R, Mariotto S, Damato V, Diamanti L, Gastaldi M, Vogrig A, Marchioni E, Guarino M. Clinical Course of Neurologic Adverse Events Associated With Immune Checkpoint Inhibitors: Focus on Chronic Toxicities. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200314. [PMID: 39298719 DOI: 10.1212/nxi.0000000000200314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
BACKGROUND AND OBJECTIVES The clinical course and the risk of chronicity of neurologic immune-related adverse events (n-irAEs) associated with immune checkpoint inhibitors (ICIs) are not well documented. This study aimed to characterize the clinical course of n-irAEs and assess the prevalence of chronic events. METHODS This nationwide, multicenter, retrospective study included patients with n-irAEs identified at 7 Italian hospitals. The clinical course of n-irAEs was categorized into fulminant (if resulted in death within 12 weeks), monophasic (if resolved within 12 weeks), and chronic (if persisted beyond 12 weeks). Chronic n-irAEs were further subdivided into active (if there was indirect evidence of ongoing inflammation [i.e., required ongoing immunosuppression, relapsed on steroid tapering, or exhibited neurologic progression]) and inactive (if patients had neurologic sequelae without ongoing inflammation). Comparisons between groups and time-to-death analyses were performed. RESULTS Sixty-six patients were included (median age: 69 years [IQR 62-75]; 53 [80%] men). n-irAEs involved the peripheral nervous system in 48 patients (73%), the central nervous system in 14 (21%), and both in 4 (6%). Twelve patients (18%) had a fulminant course, with the risk being significantly higher in those with concurrent myocarditis (OR 5.4; 95% CI [1.02-28.31]). Among 54 patients with a nonfulminant course, 23 (43%) had a monophasic n-irAE and 31 (57%) had a chronic n-irAE, of which 16 of 31 (52%) were chronic active (due to ongoing immunosuppression [69%], relapses at corticosteroid tapering [19%], or neurologic disease progression [12%]) and 15 of 31 (48%) were chronic inactive. In patients with chronic inactive n-irAEs, neurologic sequelae included cerebellar ataxia (33%), neuromuscular weakness (27%), visual loss (13%), sensory disturbances (13%), focal neurologic signs (7%), and cognitive impairment (7%). Compared with patients with monophasic events, those with chronic n-irAEs had a higher rate of severe neurologic disability at the last evaluation (p < 0.01), shorter survival (p < 0.01), and higher overall mortality (p < 0.01), primarily due to cancer progression. DISCUSSION More than half of the patients with n-irAEs who survived the acute phase developed a chronic condition. Patients with chronic n-irAEs were at higher risk of death, mainly due to cancer progression. Future studies are needed to further characterize chronic n-irAEs and identify optimal long-term management strategies.
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Affiliation(s)
- Simone Rossi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Farina
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Malvaso
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Alessandro Dinoto
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Laura Fionda
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Sara Cornacchini
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Irene Florean
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Luigi Zuliani
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Matteo Garibaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Lauletta
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Flavia Baccari
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Corrado Zenesini
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Rita Rinaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Sara Mariotto
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Valentina Damato
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Luca Diamanti
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Matteo Gastaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Alberto Vogrig
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Enrico Marchioni
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Maria Guarino
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
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Zhou H, Cai LL, Lin YF, Ma JJ. Toxicity profile of camrelizumab-based immunotherapy in older adults with advanced cancer. Sci Rep 2024; 14:18992. [PMID: 39152261 PMCID: PMC11329723 DOI: 10.1038/s41598-024-69944-w] [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: 02/08/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) have become an important cornerstone of many tumour treatments. However, the toxicity profile of immune-chemotherapy combination treatment approaches among older adult cancer patients is still unclear. Patients with any cancer who received camrelizumab-based immunotherapy were eligible for inclusion. The primary endpoints were adverse events (AEs) and immune-related adverse events (irAEs), which were defined based on Naranjo's algorithm. Patients were stratified by age (≥ 70 years and < 70 years), and comparisons were made based on the type of camrelizumab-based therapy (monotherapy, combined chemotherapy, or combined anti-VEGF therapy). A total of 185 patients were administered camrelizumab-based immunotherapy, 55 (30%) of whom were ≥ 70 years old. A total of 146 (78.9%) patients received camrelizumab-based combination treatment. The incidence of all-grade AEs was 56.8% (105 patients), while that of irAEs was 36.8% (68 patients). There was no difference in the percentage of patients experiencing any grade or grade ≥ 3 AEs between age groups. However, the frequency of irAEs (both any grade and grade ≥ 3) significantly differed by age group (P = 0.001 and 0.009, respectively). The results of multivariable analysis revealed that age ≥ 70 years was the only independent risk factor for irAEs. The results of subgroup analysis revealed that the incidence of irAEs was higher in older patients treated with camrelizumab-chemotherapy, while the incidence rates were similar between age groups in the monotherapy and combination anti-VEGF treatment subgroups. Immune-related diabetes mellitus occurred more frequently among older adults. The spectrum of irAEs showed that combination immunotherapy had more widely effects on the organ system than monotherapy. In this study, older (≥ 70 years) patients had a higher risk of all-grade and high-grade irAEs when receiving camrelizumab chemotherapy combination treatment. Notably, long-term random glucose monitoring should be performed during ICI-based immunotherapy in older cancer patients.
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Affiliation(s)
- Hong Zhou
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China.
- Department of Pharmacy, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China.
| | - Li-Li Cai
- Department of Pharmacy, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Yan-Fang Lin
- Department of Pharmacy, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Jun-Jie Ma
- School of Medicine, Huaqiao University, Quanzhou, 362021, Fujian, China
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Soto-Lanza F, Glick L, Chan C, Zhong L, Wilson N, Faiz S, Gandhi S, Naing A, Heymach JV, Shannon VR, Franco-Vega M, Liao Z, Lin SH, Palaskas NL, Wu J, Shroff GS, Altan M, Sheshadri A. Long-Term Clinical, Radiological, and Mortality Outcomes Following Pneumonitis in Nonsmall Cell Lung Cancer Patients Receiving Immune Checkpoint Inhibitors: A Retrospective Analysis. Clin Lung Cancer 2024:S1525-7304(24)00155-4. [PMID: 39183094 DOI: 10.1016/j.cllc.2024.07.017] [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: 04/26/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/27/2024]
Abstract
AIMS Despite known short-term mortality risk of immune checkpoint inhibitor (ICI) pneumonitis, its impact on 1-year mortality, long-term pulmonary function, symptom persistence, and radiological resolution remains unclear. METHODS We retrospectively analyzed 71 nonsmall cell lung cancer (NSCLC) patients treated with anti-PD(L)1 monoclonal antibodies between 2018-2021, who developed pneumonitis. Clinical and demographic covariates were collected from electronic medical record. Cox regression assessed associations with mortality, while logistic regression evaluated associations with persistent symptoms, hypoxemia, and radiological resolution. RESULTS Steroid-refractory pneumonitis (hazard ratio [HR] = 15.1, 95% confidence interval [95% CI]:3.9-57.8, P < .0001) was associated with higher 1-year mortality compared to steroid-responsive cases. However, steroid-resistant (odds ratio [OR] = 1.4, 95% CI: 0.4-5.1, P = .58) and steroid-dependent (OR = 0.4, 95% CI: 0.1-1.2, P = .08) pneumonitis were not. Nonadenocarcinoma histology (OR = 6.7, 95% CI: 1.6-46.6, P = .01), grade 3+ pneumonitis (OR = 4.6, 95% CI: 1.3-22.7, P = .03), and partial radiological resolution (OR = 6.3, 95% CI: 1.8-23.8, P = .004) were linked to increased pulmonary symptoms after pneumonitis resolution. Grade 3+ pneumonitis (OR = 8.1, 95% CI: 2.3-31.5, P = .001) and partial radiological resolution (OR = 5.45, 95% CI: 1.29-37.7, P = .03) associated with residual hypoxemia. Nonadenocarcinoma histology (OR = 3.6, 95% CI: 1.01-17.6, P = .06) and pretreatment ILAs (OR = 4.8, 95% CI: 1.14-33.09, P = .05) were associated with partial radiological resolution. CONCLUSIONS Steroid refractory pneumonitis increases 1-year mortality in NSCLC patients. Pretreatment ILAs may signal predisposition to fibrosis-related outcomes, seen as partial resolution, which in turn is associated with postresolution symptoms and residual hypoxemia. These findings offer insights for identifying patients at risk of adverse outcomes post-pneumonitis resolution.
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Affiliation(s)
- Felipe Soto-Lanza
- Department of Pulmonary Medicine, Division of Internal Medicine, MD Anderson Cancer Center, Houston, TX
| | - Lydia Glick
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX
| | - Colin Chan
- Texas A&M University School of Medicine, Houston, TX
| | - Linda Zhong
- Investigational Cancer Therapeutics, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, TX
| | - Nathaniel Wilson
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Saadia Faiz
- Department of Pulmonary Medicine, Division of Internal Medicine, MD Anderson Cancer Center, Houston, TX
| | - Saumil Gandhi
- Department of Thoracic Radiation Oncology, Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Aung Naing
- Investigational Cancer Therapeutics, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, TX
| | - John V Heymach
- Department of Thoracic-Head & Neck Medical Oncology, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, TX
| | - Vickie R Shannon
- Department of Pulmonary Medicine, Division of Internal Medicine, MD Anderson Cancer Center, Houston, TX
| | - Maria Franco-Vega
- Department of Hospital Medicine, Division of Internal Medicine, MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Department of Thoracic Radiation Oncology, Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Steven H Lin
- Department of Thoracic Radiation Oncology, Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Nicolas L Palaskas
- Department of Cardiology, Division of Internal Medicine, MD Anderson Cancer Center, Houston, TX
| | - Jia Wu
- Department of Imaging Physics, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, TX
| | - Girish S Shroff
- Department of Thoracic Imaging, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, TX
| | - Mehmet Altan
- Department of Thoracic-Head & Neck Medical Oncology, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, TX
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, Division of Internal Medicine, MD Anderson Cancer Center, Houston, TX.
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Abdel-Wahab N, Suarez-Almazor ME. Rheumatic adverse events of immune checkpoint inhibitors in cancer immunotherapy. Expert Rev Clin Immunol 2024; 20:873-893. [PMID: 38400840 DOI: 10.1080/1744666x.2024.2323966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/19/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION The advent of immune checkpoint inhibitors (ICIs) in cancer treatment has marked a transformative era, albeit tempered by immune-related adverse events (irAEs), including those impacting the musculoskeletal system. The lack of precise epidemiologic data on rheumatic irAEs is attributed to factors such as potential underrecognition, underreporting in clinical trials, and the tendency to overlook manifestations without immediate life-threatening implications, further complicating the determination of accurate incidence rates, while the complete understanding of the mechanisms driving rheumatic irAEs remains elusive. AREAS COVERED This literature review comprehensively examines rheumatic irAEs in cancer patients undergoing ICI therapy, encompassing epidemiology, risk factors, mechanisms, clinical manifestations, and current management guidance for prevalent conditions such as inflammatory arthritis, polymyalgia rheumatica, and myositis. Less frequent rheumatic and musculoskeletal irAEs are also explored, alongside insights into ongoing clinical trials testing therapeutic and preventive strategies for irAEs. A thorough literature search on Medline and the National Cancer Institute Clinical Trials Database was conducted up to October 2023 to compile relevant information. EXPERT OPINION In light of the evolving landscape of cancer immunotherapy, there is a compelling need for prospective longitudinal studies to enhance understanding and inform clinical management strategies for rheumatic irAEs.
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Affiliation(s)
- Noha Abdel-Wahab
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine; and Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Rheumatology and Rehabilitation, Assiut University Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Maria E Suarez-Almazor
- Department of Health Services Research; and Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Asao T, Shukuya T, Uemura K, Kitadai R, Yamamoto G, Mouri A, Tamaoka M, Imai R, Tsukita Y, Isobe K, Watanabe S, Kamimura M, Morita R, Kudo K, Inomata M, Tateishi K, Kakinuma K, Yoshioka H, Namba Y, Sumiyoshi I, Nakagawa T, Watanabe K, Kobayashi K, Takahashi K. Risk and survival of patients with non-small cell lung cancer and pre-existing autoimmune disorders receiving immune checkpoint blockade therapy: Survival analysis with inverse probability weighting from a nationwide, multi-institutional, retrospective study (NEJ047). Lung Cancer 2024; 194:107894. [PMID: 39029359 DOI: 10.1016/j.lungcan.2024.107894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 07/06/2024] [Accepted: 07/12/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND The risk and survival of patients with non-small cell lung cancer (NSCLC) with pre-existing autoimmune disorders (AIDs) receiving immune checkpoint blockade (ICB) therapy have not been clearly established. PATIENTS AND METHODS This multi-institutional, retrospective cohort study was conducted in collaboration with 20 centers in Japan. RESULTS In total, 229 patients with advanced or recurrent NSCLC and pre-existing AID, with or without ICB treatment from January 2010-February 2020, were included and analyzed. Among 69 patients who received ICB, 2 received two lines of ICBs with a total of 71 ICB treatments; 57 (80.3 %) and 14 (19.7 %) patients received ICB monotherapy and combination therapy, respectively. AID flares were observed in 18 patients (25.4 %, 95 % confidence interval [CI], 15.8-37.1 %) receiving ICB. AID exacerbations were more likely when NSCLC was diagnosed less than 1 year after the AID diagnosis (odds ratio 5.26 [95 % CI, 1.40-21.61]; P = 0.016). Immune-related adverse events were observed in 32 patients (45.1 %, 95 % CI, 33.2-57.3 %); 17 had grade 3 or higher. The safety profile of combination immunotherapy was not significantly different from that of the monotherapy. After inverse probability weighting, the use of ICB prolonged survival (hazard ratio 0.43 [95 % CI, 0.26-0.70]; P = 0.0006). CONCLUSIONS These findings revealed a novel risk factor for AID flares following ICB treatment, that is the diagnosis of NSCLC within 1 year of AID diagnosis, and showed that ICBs may improve survival in this population. These results support the utilization of ICB in patients with NSCLC and pre-existing AID.
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Affiliation(s)
- Tetsuhiko Asao
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takehito Shukuya
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Kohei Uemura
- Interfaculty Initiative in Information Studies, The University of Tokyo, Tokyo, Japan
| | - Rui Kitadai
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan; Department of Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Gaku Yamamoto
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Atsuto Mouri
- Department of Respiratory Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Meiyo Tamaoka
- Department of Respiratory Medicine, Toranomon Hospital, Tokyo, Japan
| | - Ryosuke Imai
- Department of Pulmonary Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yoko Tsukita
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kazutoshi Isobe
- Division of Respiratory Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Satoshi Watanabe
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Mitsuhiro Kamimura
- Department of Pulmonology, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Ryo Morita
- Department of Respiratory Medicine, Akita Kousei Medical Center, Akita, Japan
| | - Keita Kudo
- Department of Medical Oncology, National Hospital Organization Osaka Minami Medical Center, Osaka, Japan
| | - Minehiko Inomata
- First Department of Internal Medicine, Toyama University Hospital, Toyama, Japan
| | - Kazunari Tateishi
- First Department of Internal Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Kazutaka Kakinuma
- Division of Respiratory Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroshige Yoshioka
- Department of Thoracic Oncology, Kansai Medical University Hospital, Osaka, Japan
| | - Yukiko Namba
- Department of Respiratory Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Issei Sumiyoshi
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan; Department of Respiratory Medicine, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Taku Nakagawa
- Department of Thoracic Surgery, Omagari Kosei Medical Center, Akita, Japan
| | - Kana Watanabe
- Department of Respiratory Medicine, Miyagi Cancer Center, Miyagi, Japan
| | - Kunihiko Kobayashi
- Department of Respiratory Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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6
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Hamida O, Karlsson F, Lundqvist A, Gerling M, Liu LL. Cytokine release syndrome after treatment with immune checkpoint inhibitors: an observational cohort study of 2672 patients from Karolinska University Hospital in Sweden. Oncoimmunology 2024; 13:2372875. [PMID: 38974986 PMCID: PMC11225914 DOI: 10.1080/2162402x.2024.2372875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 06/22/2024] [Indexed: 07/09/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are linked to diverse immune-related adverse events (irAEs). Rare irAEs surface first in clinical practice. Here, we systematically studied the rare irAE, cytokine-release syndrome (CRS), in a cohort of 2672 patients treated with ICIs at Karolinska University Hospital in Stockholm, Sweden. We find that the risk of ICI-induced CRS - defined as fever, negative microbiological findings and absence of other probable causes within 30 days after ICI treatment - is approximately 1%, higher than previously reported. ICI-induced CRS was often mild and rechallenge with ICIs after mild CRS was generally safe. However, two out of 28 patients experienced high-grade CRS, and one was fatal. While C-reactive protein (CRP) and procalcitonin were not discriminative of fatal CRS, our data suggest that the quick Sequential Organ Failure Assessment (qSOFA) score might identify high-risk patients. These data provide a framework for CRS risk assessment and motivate multicenter studies to improve early CRS diagnosis.
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Affiliation(s)
- Osama Hamida
- Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Frans Karlsson
- Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Lundqvist
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marco Gerling
- Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Lisa L. Liu
- Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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7
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Ma S, Li F, Wang L. The Construction of a Nomogram Using the Pan-Immune-Inflammation Value Combined with a PILE Score for Immunotherapy Prediction Prognosis in Advanced NSCLC. Cancer Manag Res 2024; 16:741-751. [PMID: 38974092 PMCID: PMC11227331 DOI: 10.2147/cmar.s461964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 06/18/2024] [Indexed: 07/09/2024] Open
Abstract
Purpose The purpose of this study was to investigate the predictive value of Pan-Immune-Inflammation Value (PIV) combined with the PILE score for immunotherapy in patients with advanced non-small cell lung cancer (NSCLC) and to construct a nomogram prediction model to provide reference for clinical work. Patients and Methods Patients with advanced NSCLC who received ICIs treatment in Qingdao Municipal Hospital from January 2019 to December 2021 were selected as the study subjects. The chi-square test, Kaplan-Meier survival analysis, and Cox proportional risk regression analysis were used to evaluate the prognosis. The results were visualized by a nomogram, and the performance of the model was judged by indicators such as the area under the subject operating characteristic curve (AUC) and C-index. The patients were divided into high- and low-risk groups by PILE score, and the prognosis of patients in different risk groups was evaluated. Results Multivariate Cox regression analysis showed that immune-related adverse events (irAEs) were prognostic factors for overall survival (OS) improvement, and ECOG PS score ≥2, bone metastases before treatment, and high PIV expression were independent risk factors for OS. The C index of OS predicted by the nomogram model is 0.750 (95% CI: 0.677-0.823), and the Calibration and ROC curves show that the model has good prediction performance. Compared with the low-risk group, patients in the high-risk group of PILE were associated with a higher inflammatory state and poorer physical condition, which often resulted in a poorer prognosis. Conclusion PIV can be used as a prognostic indicator for patients with advanced NSCLC treated with ICIs, and a nomogram prediction model can be constructed to evaluate the survival prediction of patients, thus contributing to better clinical decision-making and prognosis assessment.
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Affiliation(s)
- Shixin Ma
- Graduate School, Dalian Medical University, Dalian, Liaoning, 116000, People’s Republic of China
- Department of Thoracic Surgery, Qingdao Municipal Hospital, Qingdao, Shandong, 266071, People’s Republic of China
| | - Fei Li
- Department of Thoracic Surgery, Qingdao Municipal Hospital, Qingdao, Shandong, 266071, People’s Republic of China
| | - Lunqing Wang
- Department of Thoracic Surgery, Qingdao Municipal Hospital, Qingdao, Shandong, 266071, People’s Republic of China
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Lim AM, Le Tourneau C, Hurt C, Laskar SG, Steuer CE, Chow VLY, Szturz P, Henson C, Day AT, Bates JE, Lazarakis S, McDowell L, Mehanna H, Yom SS. Assessment of endpoint definitions in recurrent and metastatic mucosal head and neck squamous cell carcinoma trials: Head and Neck Cancer International Group consensus recommendations. Lancet Oncol 2024; 25:e308-e317. [PMID: 38936389 DOI: 10.1016/s1470-2045(24)00068-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 06/29/2024]
Abstract
Transparent and precise endpoint definitions are a crucial aspect of clinical trial conduct and reporting, and are used to communicate the benefit of an intervention. Previous studies have identified inconsistencies in endpoint definitions across oncological clinical trials. Here, the Head and Neck Cancer International Group assessed endpoint definitions from phase 3 trials or trials considered practice-changing for patients with recurrent or metastatic mucosal head and neck squamous cell carcinoma, published between 2008 and 2021. We identify considerable and global heterogeneity in endpoint definitions, which undermines the interpretation of results and development of future studies. We show how fundamental components of even incontrovertible endpoints such as overall survival vary widely, highlighting an urgent need for increased rigour in reporting and harmonisation of endpoints.
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Affiliation(s)
- Annette M Lim
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.
| | - Christophe Le Tourneau
- Department of Drug Development and Innovation (D3i), Institut Curie, Paris, France; INSERM U900 Research unit, Institut Curie, Paris, France; Paris-Saclay University, Paris, France
| | - Chris Hurt
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Sarbani G Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Conor E Steuer
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Velda L Y Chow
- Division of Head and Neck Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong Special Administrative Region, China
| | - Petr Szturz
- Department of Oncology, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland
| | - Christina Henson
- Department of Radiation Oncology, Stephenson Cancer Center, University of Oklahoma, OK, USA
| | - Andrew T Day
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, TX, USA
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Lachlan McDowell
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), University of Birmingham, Edgbaston, Birmingham, UK
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, CA, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, CA, USA.
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Silverstein J, Goyal N, Tsai KK. For the Long Haul: Management of Long-Term Survivors after Melanoma Systemic Therapy. Curr Oncol Rep 2024; 26:804-817. [PMID: 38780676 DOI: 10.1007/s11912-024-01541-6] [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] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW This review summarizes the latest advancements in survivorship care for patients with advanced melanoma who received systemic therapy and emphasizes the areas where more research is needed. RECENT FINDINGS Over the last decade there have been remarkable advances in the treatment of advanced and metastatic melanoma. Due to these novel treatments, including several immune checkpoint inhibitors and tyrosine kinase inhibitors, there are and will continue to be increasing numbers of long-term melanoma survivors who have been treated with systemic therapy. These patients will navigate new challenges are they are essentially among the first long term survivors after these novel therapies. Survivorship care focuses on improving the health-related quality of life of patients including the physical, emotional, social and functional effects of cancer that begin at diagnosis and continue through the end of life. Survivorship also includes screening for cancer recurrence and second cancers. As the number of melanoma survivors who received systemic therapy continues to grow, the survivorship care plan will become increasingly important for optimal care of patients even after their cancer treatments. Understanding the many domains of survivorship care for this group of patients is imperative for their care now and to identify unmet needs for future research.
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Affiliation(s)
- Jordyn Silverstein
- Department of Medicine, Division of Hematology/Oncology, University of California, Los Angeles (UCLA), 757 Westwood Plaza, Los Angeles, CA, 90095, USA.
| | - Neha Goyal
- Department of Psycho-Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Katy K Tsai
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco (UCSF), San Francisco, CA, USA
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Nishihama K, Okano Y, Inoue C, Maki K, Eguchi K, Tanaka S, Takeshita A, Uemura M, Yasuma T, Suzuki T, Gabazza EC, Yano Y. A case of rapidly progressive insulin-dependent diabetes mellitus without islet autoantibodies developed over two years after the first dose of nivolumab. Diabetol Int 2024; 15:583-588. [PMID: 39101192 PMCID: PMC11291771 DOI: 10.1007/s13340-024-00703-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: 02/03/2023] [Accepted: 02/15/2024] [Indexed: 08/06/2024]
Abstract
The case was an 80-year-old Japanese man. He was diagnosed with right renal cell carcinoma when he was 74. After laparoscopic radical nephrectomy, the patient received interferon, sorafenib, axitinib, and nivolumab therapy. The patient developed rapid progressive insulin-dependent diabetes mellitus (DM) after 46 courses of nivolumab monotherapy (772 days from the first nivolumab treatment). Glutamic acid decarboxylase antibody, islet cell cytoplasmic antibody, islet cell antigen-2 antibody, insulin antibody, and zinc transporter 8 antibody were all negative. Human leukocyte antigen (HLA) typing showed DRB1*09:01, DRB1 *13:02, DQB1*03:03, and DQB1 *06:04. Multiple daily insulin injections were started. However, controlling his blood glucose by standard multiple daily insulin injection treatments was difficult. The patient survived more than two years after the onset of immune checkpoint inhibitor-associated DM (ICI-DM). This is a valuable report of late-onset ICI-DM with a detailed patient background and clinical course over two years after the first dose of nivolumab.
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Affiliation(s)
- Kota Nishihama
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Yuko Okano
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Chisa Inoue
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Kanako Maki
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Kazuhito Eguchi
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Soichiro Tanaka
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Atsuro Takeshita
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Mei Uemura
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Taro Yasuma
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Toshinari Suzuki
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Esteban C. Gabazza
- Department of Immunology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yutaka Yano
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
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11
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Lee CM, Wang M, Rajkumar A, Calabrese C, Calabrese L. A scoping review of vasculitis as an immune-related adverse event from checkpoint inhibitor therapy of cancer: Unraveling the complexities at the intersection of immunology and vascular pathology. Semin Arthritis Rheum 2024; 66:152440. [PMID: 38579593 DOI: 10.1016/j.semarthrit.2024.152440] [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: 12/11/2023] [Revised: 03/05/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND/PURPOSE Vasculitis as an immune-related adverse event (irAE) from checkpoint inhibitor therapy (ICI) to treat cancer is a rare clinical event, and little is known regarding its nosology, clinical manifestations, or response to treatment and outcomes. METHODS To address these gaps, we used the Preferred Reporting Items for Systemic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework to further define this complication. Two independent PUBMED searches in September and November of 2022 revealed 127 publications with 37 excluded from title by relevance, 43 excluded by article type, and 23 excluded due to lack of biopsy results, or biopsy negative for vasculitis. Twenty-nine documented cases from 24 publications were included for final analysis. Basic demographics, ICI details, timing of onset of vasculitis symptoms, irAE treatment and outcomes were collected. The vasculitides were classified using 2022 ACR/EULAR Vasculitis Classification Criteria as well as 2012 Revised Chapel-Hill Nomenclature. Adaptations from Naidoo et al. 2023 [1] consensus definitions for irAEs were used and efforts were made to classify steroid-responsive versus unresponsive irAEs. RESULTS Of the 29 cases reviewed, the average age of patients was 62.1 ± 11.0, composed of 58.6 % (n = 17) male and 41.3 % (n = 12) female. Prominent cancer types were lung cancer (41.4 %; n = 12), melanoma (41.4 %; n = 12), and renal cancer (10.3 %; n = 3), with majority being stage 4 (75.9 %, n = 22) and stage 3 (10.3 %, n = 3). Only 8 cases met the ACR/EULAR criteria, and by Chapel-Hill Nomenclature, approximately a third were small-vessel vasculitis (31.0 %; n = 9) with n = 4 positive for ANCA. Most biopsies were taken from the skin (37.9 %, n = 11) and kidney (24.1 %, n = 7). Patients were either treated with single (65.5 %, n = 19), dual (17.2 %; n = 5), or sequential (17.2 %; n = 5) ICI regimen which included anti-PD-1 therapy in all but one case, with mean of 8.7 ± 10.5 cycles received. Mean time to onset of symptoms from start of ICI was 7.2 ± 7.8 months, with 55.2 % occurring >3 months since the initial immunotherapy. Vasculitis treatment included glucocorticoids in 96 % of cases and immunotherapy was often discontinued (44.8 %; n = 13). Clinical improvement of irAE was documented in 86.2 % (n = 25). Data were missing in terms of fate of ICI (34.5 %; n = 10) and tumor outcomes (41.4 %; n = 12). Cancer progressed in 20.7 % (n = 6), stable in 34.5 % (n = 10) cases, and 6 patients died of all-causes. CONCLUSION Vasculitis as an irAE appears clinically heterogeneous and rare. Among reported cases with adequate documentation, vasculitis is of delayed onset following the initiation of immunotherapy. Outcomes of ICI-vasculitis were generally favorable, responding to glucocorticoids and immunotherapy withdrawal. There is an urgent need for more standardized reporting of rare irAEs such as vasculitis to clarify clinical risks, classification, relationship to immunotherapy and outcomes.
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Affiliation(s)
- Chan-Mi Lee
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Margaret Wang
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Aarthi Rajkumar
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Cassandra Calabrese
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States
| | - Leonard Calabrese
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States.
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12
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Cariou PL, Pobel C, Michot JM, Danlos FX, Besse B, Carbonnel F, Mariette X, Marabelle A, Messayke S, Robert C, Routier E, Noël N, Lambotte O. Impact of immunosuppressive agents on the management of immune-related adverse events of immune checkpoint blockers. Eur J Cancer 2024; 204:114065. [PMID: 38643707 DOI: 10.1016/j.ejca.2024.114065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Immune checkpoint blockers (ICBs) can induce immune-related adverse events (irAEs) whose management is based on expert opinion and may require the prescription of steroids and/or immunosuppressants (ISs). Recent data suggest that these treatments can reduce the effectiveness of ICBs. OBJECTIVE To investigate the relationship between the use of steroids and/or ISs and overall survival (OS) and progression-free survival (PFS) among ICB-treated patients with an irAE. METHODS We prospectively collected data from the medical records of patients with solid tumors or lymphoma in the French REISAMIC cohort and who had been treated with ICBs between June 2014 and June 2020. RESULTS 184 ICB-treated patients experienced at least one Common Terminology Criteria for Adverse Events grade ≥ 2 irAE. 107 (58.2%) were treated with steroids alone, 20 (10.9%) with steroids plus IS, 57 (31.0%) not received steroids or IS. The median OS was significantly shorter for patients treated with steroids alone (25.2 months [95% confidence interval (CI): 22.3-32.4] than for patients treated without steroids or IS (63 months [95%CI: 40.4-NA]) and those receiving an IS with steroids (53.4 months [95%CI: 47.3-NA]) (p < 0.001). The median PFS was significantly shorter for patients treated with steroids alone (17.0 months [95%CI: 11.7-22.9]) than for patients treated without steroids or IS (33.9 months [95%CI: 18.0-NA]) and those receiving an IS with steroids (41.1 months [95%CI: 26.2-NA]) (p = 0.006). There were no significant intergroup differences in the hospital admission and infection rates. CONCLUSION In a prospective cohort of ICB-treated patients, the use of IS was not associated with worse OS or PFS, contrasting with the use of steroids for the management of irAEs.
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Affiliation(s)
- Pierre-Louis Cariou
- Université Paris Saclay, AP-HP, Hôpital de Bicêtre, Department of Internal Medicine, UMR 1184, CEA INSERM, FHU CARE, Le Kremlin Bicêtre, France
| | - Cédric Pobel
- Drug Development Department (DITEP), Gustave Roussy, 94805 Villejuif, France
| | - Jean-Marie Michot
- Drug Development Department (DITEP), Gustave Roussy, 94805 Villejuif, France
| | | | - Benjamin Besse
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - Franck Carbonnel
- AP-HP, Department of Gastroenterology, University Hospital of Bicêtre, Paris Sud University, FHU CARE, 78 Rue du General Leclerc, 94270 Le Kremlin-Bicetre, France
| | - Xavier Mariette
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, Rheumatology Department, INSERM UMR 1184, FHU CARE, Paris, Le Kremlin Bicêtre, France
| | - Aurélien Marabelle
- Drug Development Department (DITEP), Gustave Roussy, 94805 Villejuif, France
| | - Sabine Messayke
- Gustave Roussy - Paris-Saclay University, Pharmacovigilance Unit, 94800 Villejuif, France
| | - Caroline Robert
- Dermatology Service, Department of Medicine, Gustave Roussy and Paris-Saclay University, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - Emilie Routier
- Dermatology Service, Department of Medicine, Gustave Roussy and Paris-Saclay University, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - Nicolas Noël
- Université Paris Saclay, AP-HP, Hôpital de Bicêtre, Department of Internal Medicine, UMR 1184, CEA INSERM, FHU CARE, Le Kremlin Bicêtre, France
| | - Olivier Lambotte
- Université Paris Saclay, AP-HP, Hôpital de Bicêtre, Department of Internal Medicine, UMR 1184, CEA INSERM, FHU CARE, Le Kremlin Bicêtre, France.
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13
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Ali M, Eid M, Saliby RM, Choi S, McKay RR, Siva S, Braun DA, Chen YW. Emerging Novel Functional Imaging and Immunotherapy in Renal Cell Carcinoma and Current Treatment Sequencing Strategies After Immunotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438658. [PMID: 38875505 DOI: 10.1200/edbk_438658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
The management of renal cell carcinoma (RCC) has advanced significantly in the past two decades. Many promising functional imaging modalities such as radiolabeled tracer targeting carbonic anhydrase IX and prostate-specific membrane antigen are under development to detect primary kidney tumors, stage systemic disease, and assess treatment response in RCC. Immune checkpoint inhibitors targeting PD-1 and cytotoxic T-cell lymphocyte-4 have changed the treatment paradigm in advanced RCC. Trials investigating novel mechanisms such as LAG-3 immune checkpoint inhibition, chimeric antigen receptor T-cell therapies, and T-cell engagers targeting RCC-associated antigens are currently ongoing. With the rapidly changing treatment landscape of RCC, the treatment sequence strategies will continue to evolve. Familiarity with the toxicities associated with the therapeutic agents and how to manage them are essential to achieve optimal patient outcomes. This review summarizes the recent developments of functional imaging and immunotherapy strategies in RCC, and the evidence supports treatment sequencing.
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Affiliation(s)
- Muhammad Ali
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Marc Eid
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Renee Maria Saliby
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
- Center of Molecular and Cellular Oncology, Yale Cancer Center, Yale School of Medicine, New Haven, CT
| | - Sharon Choi
- Division of Hematology Oncology, University of California San Diego, San Diego, CA
| | - Rana R McKay
- Division of Hematology Oncology, University of California San Diego, San Diego, CA
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - David A Braun
- Center of Molecular and Cellular Oncology, Yale Cancer Center, Yale School of Medicine, New Haven, CT
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Yu-Wei Chen
- Division of Hematology Oncology, University of California San Diego, San Diego, CA
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14
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Alserawan L, Mulet M, Anguera G, Riudavets M, Zamora C, Osuna-Gómez R, Serra-López J, Barba Joaquín A, Sullivan I, Majem M, Vidal S. Kinetics of IFNγ-Induced Cytokines and Development of Immune-Related Adverse Events in Patients Receiving PD-(L)1 Inhibitors. Cancers (Basel) 2024; 16:1759. [PMID: 38730712 PMCID: PMC11083441 DOI: 10.3390/cancers16091759] [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: 02/29/2024] [Revised: 04/25/2024] [Accepted: 04/27/2024] [Indexed: 05/13/2024] Open
Abstract
Immune checkpoint inhibitors (ICI) have the potential to trigger unpredictable immune-related adverse events (irAEs), which can be severe. The underlying mechanisms of these events are not fully understood. As PD-L1 is upregulated by IFN, the heightened immune activation resulting from PD-1/PD-L1 inhibition may enhance the IFN response, triggering the expression of IFN-inducible genes and contributing to irAE development and its severity. In this study, we investigated the interplay between irAEs and the expression of IFN-inducible chemokines and cytokines in 134 consecutive patients with solid tumours treated with PD-(L)1 inhibitors as monotherapy or in combination with chemotherapy or other immunotherapy agents. We compared the plasma levels of IFN-associated cytokines (CXCL9/10/11, IL-18, IL-10, IL-6 and TGFβ) at various time points (at baseline, at the onset of irAE and previous to irAE onset) in three patient groups categorized by irAE development and severity: patients with serious irAEs, mild irAEs and without irAEs after PD-(L)1 inhibitors. No differences were observed between groups at baseline. However, patients with serious irAEs exhibited significant increases in CXCL9/10/11, IL-18 and IL-10 levels at the onset of the irAE compared to baseline. A network analysis and correlation patterns highlighted a robust relationship among these chemokines and cytokines at serious-irAE onset. Combining all of the analysed proteins in a cluster analysis, we identified a subgroup of patients with a higher incidence of serious irAEs affecting different organs or systems. Finally, an ROC analysis and a decision tree model proposed IL-18 levels ≥ 807 pg/mL and TGFβ levels ≤ 114 pg/mL as predictors for serious irAEs in 90% of cases. In conclusion, our study elucidates the dynamic changes in cytokine profiles associated with serious irAE development during treatment with PD-(L)1 inhibitors. The study's findings offer valuable insights into the intricate IFN-induced immune responses associated with irAEs and propose potential predictive markers for their severity.
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Affiliation(s)
- Leticia Alserawan
- Immunology-Inflammatory Diseases, Biomedical Research Institute Sant Pau (IIB Sant Pau), 08025 Barcelona, Spain; (L.A.); (M.M.); (C.Z.); (R.O.-G.)
- Department of Immunology, Hospital Clínic Barcelona, 08036 Barcelona, Spain
| | - Maria Mulet
- Immunology-Inflammatory Diseases, Biomedical Research Institute Sant Pau (IIB Sant Pau), 08025 Barcelona, Spain; (L.A.); (M.M.); (C.Z.); (R.O.-G.)
| | - Geòrgia Anguera
- Department of Medical Oncology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (G.A.); (M.R.); (J.S.-L.); (A.B.J.); (I.S.); (M.M.)
| | - Mariona Riudavets
- Department of Medical Oncology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (G.A.); (M.R.); (J.S.-L.); (A.B.J.); (I.S.); (M.M.)
- Department of Pneumologie, Hôpital Cochin—APHP Centre, 75014 Paris, France
| | - Carlos Zamora
- Immunology-Inflammatory Diseases, Biomedical Research Institute Sant Pau (IIB Sant Pau), 08025 Barcelona, Spain; (L.A.); (M.M.); (C.Z.); (R.O.-G.)
| | - Rubén Osuna-Gómez
- Immunology-Inflammatory Diseases, Biomedical Research Institute Sant Pau (IIB Sant Pau), 08025 Barcelona, Spain; (L.A.); (M.M.); (C.Z.); (R.O.-G.)
| | - Jorgina Serra-López
- Department of Medical Oncology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (G.A.); (M.R.); (J.S.-L.); (A.B.J.); (I.S.); (M.M.)
| | - Andrés Barba Joaquín
- Department of Medical Oncology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (G.A.); (M.R.); (J.S.-L.); (A.B.J.); (I.S.); (M.M.)
| | - Ivana Sullivan
- Department of Medical Oncology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (G.A.); (M.R.); (J.S.-L.); (A.B.J.); (I.S.); (M.M.)
| | - Margarita Majem
- Department of Medical Oncology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (G.A.); (M.R.); (J.S.-L.); (A.B.J.); (I.S.); (M.M.)
| | - Silvia Vidal
- Immunology-Inflammatory Diseases, Biomedical Research Institute Sant Pau (IIB Sant Pau), 08025 Barcelona, Spain; (L.A.); (M.M.); (C.Z.); (R.O.-G.)
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15
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Dang S, Li X, Liu H, Zhang S, Li W. Toxicity profiles of immune checkpoint inhibitors for recurrent or metastatic head and neck squamous cell carcinoma: A systematic review and meta-analysis. Cancer Med 2024; 13:e7119. [PMID: 38553943 PMCID: PMC10980932 DOI: 10.1002/cam4.7119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/17/2024] [Accepted: 03/09/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are widely used in recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC); however, the toxicity profiles are inconclusive. METHODS Clinical trials evaluating ICIs for R/M HNSCC were searched from online databases. The characteristics of the studies and the results of incidences of any grade treatment-related adverse events (trAEs), grade three or more trAEs, treatment-related deaths, trAEs leading to discontinuation of treatment, and specific trAEs were extracted. RESULTS Twenty studies with 3756 patients were included. The pooled incidences of any grade trAEs, grade three or more trAEs, treatment-related deaths, trAEs leading to discontinuation of treatment for overall population were 62.07% (95% CI, 59.07%-65.02%), 13.82% (95% CI, 11.23%-16.62%), 0.39% (95% CI, 0.15%-0.71%), 3.99% (95% CI, 2.36%-5.95%), respectively. Programmed cell death protein 1 (PD-1) inhibitors monotherapy and ICIs combination therapy had significantly higher incidences of any grade trAEs (odds ratio [OR], 1.25, 95% CI, 1.05-1.49 and 1.36, 95% CI, 1.15-1.60, respectively), grade three or more trAEs (OR, 1.41, 95% CI, 1.08-1.84 and 1.79, 95% CI, 1.39-2.30, respectively), trAEs leading to discontinuation of treatment (OR, 3.98, 95% CI, 2.06-7.70 and 10.14, 95% CI, 5.49-18.70, respectively) compared with programmed death-ligand 1 (PD-L1) inhibitors monotherapy. ICIs combination therapy had a significantly higher incidence of grade three or more trAEs compared with PD-1 inhibitors monotherapy (OR, 1.27, 95% CI, 1.03-1.55); however, the incidences of any grade trAEs and trAEs leading to discontinuation of treatment were not significant different. CONCLUSIONS Our study suggests that the incidences of grade three or more trAEs, treatment-related deaths, and trAEs leading to discontinuation of treatment are low in R/M HNSCC patients treated with ICIs. PD-L1 inhibitors monotherapy may be safer compared with PD-1 inhibitors monotherapy and ICIs combination therapy.
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Affiliation(s)
- Shoutao Dang
- Cancer Center, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Xinyu Li
- Cancer Center, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Heshu Liu
- Cancer Center, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Shuyang Zhang
- Cancer Center, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Wei Li
- Cancer Center, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
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16
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Suijkerbuijk KPM, van Eijs MJM, van Wijk F, Eggermont AMM. Clinical and translational attributes of immune-related adverse events. NATURE CANCER 2024; 5:557-571. [PMID: 38360861 DOI: 10.1038/s43018-024-00730-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/12/2024] [Indexed: 02/17/2024]
Abstract
With immune checkpoint inhibitors (ICIs) becoming the mainstay of treatment for many cancers, managing their immune-related adverse events (irAEs) has become an important part of oncological care. This Review covers the clinical presentation of irAEs and crucial aspects of reversibility, fatality and long-term sequelae, with special attention to irAEs in specific patient populations, such as those with autoimmune diseases. In addition, the genetic basis of irAEs, along with cellular and humoral responses to ICI therapy, are discussed. Detrimental effects of empirically used high-dose steroids and second-line immunosuppression, including impaired ICI effectiveness, call for more tailored irAE-treatment strategies. We discuss open therapeutic challenges and propose potential avenues to accelerate personalized management strategies and optimize outcomes.
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Affiliation(s)
- Karijn P M Suijkerbuijk
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Mick J M van Eijs
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Femke van Wijk
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alexander M M Eggermont
- University Medical Center Utrecht and Princess Máxima Center, Utrecht, the Netherlands
- Comprehensive Cancer Center Munich of the Technical University of Munich and the Ludwig Maximilian University, Munich, Germany
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17
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Fujiwara Y, Cortellini A, Naqash AR. Association of Survival With Immune-Related Adverse Events-Time to Consider the Duration of Treatment. JAMA Dermatol 2024; 160:368-369. [PMID: 38265810 DOI: 10.1001/jamadermatol.2023.5594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Yu Fujiwara
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Alessio Cortellini
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Department of Surgery and Cancer, Imperial College London, London, England
| | - Abdul Rafeh Naqash
- Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City
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18
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Murtagh G, deFilippi C, Zhao Q, Barac A. Circulating biomarkers in the diagnosis and prognosis of immune checkpoint inhibitor-related myocarditis: time for a risk-based approach. Front Cardiovasc Med 2024; 11:1350585. [PMID: 38410245 PMCID: PMC10894940 DOI: 10.3389/fcvm.2024.1350585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 02/28/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that block immune checkpoints and therefore activate immune cells, allowing them to recognize and attack cancer cells. ICIs have revolutionized oncology practice, but their use has been complicated by immune-related adverse events (irAEs). Of cardiovascular (CV) irAEs, ICI-related myocarditis has received significant attention due to high mortality rates, ranging from 25% to 50%, despite its overall low incidence. Establishing the early diagnosis of ICI-myocarditis is important for early initiation of steroids and consideration of hospitalization in patients who are at risk for hemodynamic compromise and need high acuity care in a tertiary setting. In this review, we summarize the diagnostic and prognostic tools for ICI-myocarditis, including electrocardiography, echocardiography, cardiac magnetic resonance imaging, with emphasis on circulating biomarkers. Cardiac troponins (cTns) are an essential component of the diagnosis of ICI-myocarditis, and we provide a summary of the recent studies that utilized different assays (cTnI vs. cTnT) and outcomes (diagnosis vs. prognosis including major adverse cardiac outcomes). With the exponential increase in ICI use across different oncology indications, there is a major need to include biomarkers in risk stratification to guide diagnosis and treatment. Our review proposes a framework for future multisite registries, including cTn evaluation at baseline and at the time of irAE suspicion, with development of central biobanking to allow head-to-head evaluation and clinical validation of different biomarker assays in ICI-myocarditis. This approach, with the inclusion of CV biomarkers into clinical and pragmatic oncology trials, holds promise to improve the early recognition and management of ICI-myocarditis and CV irAEs, thus leading to better outcomes.
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Affiliation(s)
- Gillian Murtagh
- Core Diagnostics, Abbott Laboratories, Abbott Park, IL, United States
| | | | - Qiong Zhao
- Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Ana Barac
- Inova Schar Heart and Vascular, Falls Church, VA, United States
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19
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Soussan S, Pupier G, Cremer I, Joubert PE, Sautès-Fridman C, Fridman W, Sibéril S. Unraveling the complex interplay between anti-tumor immune response and autoimmunity mediated by B cells and autoantibodies in the era of anti-checkpoint monoclonal antibody therapies. Front Immunol 2024; 15:1343020. [PMID: 38318190 PMCID: PMC10838986 DOI: 10.3389/fimmu.2024.1343020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/05/2024] [Indexed: 02/07/2024] Open
Abstract
The intricate relationship between anti-tumor immunity and autoimmunity is a complex yet crucial aspect of cancer biology. Tumor microenvironment often exhibits autoimmune features, a phenomenon that involves natural autoimmunity and the induction of humoral responses against self-antigens during tumorigenesis. This induction is facilitated by the orchestration of anti-tumor immunity, particularly within organized structures like tertiary lymphoid structures (TLS). Paradoxically, a significant number of cancer patients do not manifest autoimmune features during the course of their illness, with rare instances of paraneoplastic syndromes. This discrepancy can be attributed to various immune-mediated locks, including regulatory or suppressive immune cells, anergic autoreactive lymphocytes, or induction of effector cells exhaustion due to chronic stimulation. Overcoming these locks holds the risk to induce autoimmune mechanisms during cancer progression, a phenomenon notably observed with anti-immune checkpoint therapies, in contrast to more conventional treatments like chemotherapy or radiotherapy. Therefore, the challenge arises in managing immune-related adverse events (irAEs) induced by immune checkpoint inhibitors treatment, as decoupling them from the anti-tumor activity poses a significant clinical dilemma. This review summarizes recent advances in understanding the link between B-cell driven anti-tumor responses and autoimmune reactions in cancer patients, and discusses the clinical implications of this relationship.
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Affiliation(s)
| | | | | | | | | | | | - Sophie Sibéril
- Centre de recherche des Cordeliers, INSERM U1138, Sorbonne Université, Université Paris Cité, Paris, France
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20
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Daetwyler E, Wallrabenstein T, König D, Cappelli LC, Naidoo J, Zippelius A, Läubli H. Corticosteroid-resistant immune-related adverse events: a systematic review. J Immunother Cancer 2024; 12:e007409. [PMID: 38233099 PMCID: PMC10806650 DOI: 10.1136/jitc-2023-007409] [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] [Accepted: 10/28/2023] [Indexed: 01/19/2024] Open
Abstract
Immune checkpoint inhibitor (ICI) treatment has become an important therapeutic option for various cancer types. Although the treatment is effective, ICI can overstimulate the patient's immune system, leading to potentially severe immune-related adverse events (irAEs), including hepatitis, colitis, pneumonitis and myocarditis. The initial mainstay of treatments includes the administration of corticosteroids. There is little evidence how to treat steroid-resistant (sr) irAEs. It is mainly based on small case series or single case reports. This systematic review summarizes available evidence about sr-irAEs. We conducted a systematic literature search in PubMed. Additionally, we included European Society for Medical Oncology, Society for Immunotherapy of Cancer, National Comprehensive Cancer Network and American Society of Clinical Oncology Guidelines for irAEs in our assessment. The study population of all selected publications had to include patients with cancer who developed hepatitis, colitis, pneumonitis or myocarditis during or after an immunotherapy treatment and for whom corticosteroid therapy was not sufficient. Our literature search was not restricted to any specific cancer diagnosis. Case reports were also included. There is limited data regarding life-threatening sr-irAEs of colon/liver/lung/heart and the majority of publications are single case reports. Most publications investigated sr colitis (n=26), followed by hepatitis (n=21), pneumonitis (n=17) and myocarditis (n=15). There is most data for mycophenolate mofetil (MMF) to treat sr hepatitis and for infliximab, followed by vedolizumab, to treat sr colitis. Regarding sr pneumonitis there is most data for MMF and intravenous immunoglobulins (IVIG) while data regarding infliximab are conflicting. In sr myocarditis, most evidence is available for the use of abatacept or anti-thymocyte globulin (ATG) (both with or without MMF) or ruxolitinib with abatacept. This review highlights the need for prompt recognition and treatment of sr hepatitis, colitis, pneumonitis and myocarditis. Guideline recommendations for sr situations are not defined precisely. Based on our search, we recommend-as first line treatment-(1) MMF for sr hepatitis, (2) infliximab for sr colitis, followed by vedolizumab, (3) MMF and IVIG for sr pneumonitis and (4) abatacept or ATG (both with or without MMF) or ruxolitinib with abatacept for sr myocarditis. These additional immunosuppressive agents should be initiated promptly if there is no sufficient response to corticosteroids within 3 days.
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Affiliation(s)
- Eveline Daetwyler
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Till Wallrabenstein
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Division of Hematology and Medical Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - David König
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Laura C Cappelli
- Divison of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Alfred Zippelius
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Heinz Läubli
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
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21
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Güven DC, Thong MS, Arndt V. Survivorship outcomes in patients treated with immune checkpoint inhibitors: a scoping review. J Cancer Surviv 2024:10.1007/s11764-023-01507-w. [PMID: 38175366 DOI: 10.1007/s11764-023-01507-w] [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: 09/15/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have become a central part of cancer care. However, the survivorship outcomes in patients treated with ICIs are understudied. Therefore, we conducted a scoping review to evaluate the current status of the field and to establish research gaps regarding survivorship outcomes with ICIs in real-life cohorts. METHODS We used the Web of Science, PubMed, and Embase databases to systematically filter published studies with real-life cohorts from January 1, 2010, until October 19, 2022. Studies evaluating at least one survivorship outcome in ICI-treated patients were included. RESULTS A total of 39 papers were included. Quality of life (QoL) (n = 23), toxicity burden (n = 16), and psychosocial issues (n = 9) were the most frequently evaluated survivorship outcomes. Anti-PD-1/PD-L1 monotherapy and a response to treatment were associated with better QoL. In addition, the ICIs were associated with grade 3 or higher immune-related adverse events (irAEs) in 10-15% and late/long-term irAEs in 20-30% of the survivors. Regarding psychosocial problems, over 30% of survivors showed evidence of anxiety and depression, and 30-40% of survivors reported neurocognitive impairments. CONCLUSION The survivors treated with ICIs have impairments in most survivorship domains. Further research is needed to gather data on the understudied survivorship outcomes like late and long-term effects, fertility, financial toxicity, and return to work in survivors treated with ICIs. IMPLICATIONS FOR CANCER SURVIVORS Available evidence demonstrates that a significant portion of survivors treated with ICIs have a significant toxicity burden, lower QoL than the general population, and a high rate of psychosocial problems.
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Affiliation(s)
- Deniz Can Güven
- Department of Medical Oncology, Hacettepe University Cancer Institute, 06100 Sihhiye, Ankara, Turkey.
- Health Sciences University, Elazig City Hospital, Elazig, Turkey.
- Unit of Cancer Survivorship, Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Melissa Sy Thong
- Unit of Cancer Survivorship, Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Volker Arndt
- Unit of Cancer Survivorship, Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
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22
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Motomura Y, Urai S, Hirota Y, Takegawa N, Bando H, Yamamoto M, Fukuoka H, Tsuda M, Ogawa W. Type 1 diabetes mellitus affected by potential toxicity from long-term use of nivolumab. Diabetol Int 2024; 15:130-134. [PMID: 38264226 PMCID: PMC10800322 DOI: 10.1007/s13340-023-00659-5] [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: 06/26/2023] [Accepted: 08/09/2023] [Indexed: 01/25/2024]
Abstract
We present a case of type 1 diabetes mellitus (T1DM) that developed in a 53-year-old man after long-term treatment with nivolumab. The patient underwent total gastrectomy for gastric cancer at 40 years of age, and he was started on nivolumab at age 48 years for treatment of a recurrent lesion that proved resistant to standard chemotherapy. Nivolumab treatment resulted in complete response, but, after the 136th infusion of the drug at age 53 years, the patient was hospitalized for sudden onset of diabetic ketoacidosis. He was diagnosed with immune checkpoint inhibitor-induced T1DM (ICI-DM), which developed 1988 days (284 weeks) after initiation of nivolumab. HLA typing revealed disease susceptibility alleles for both fulminant T1DM and ICI-DM. With the increased survival after the ICI treatment, delayed-onset irAEs after long-term use of ICI have been reported; however, delayed-onset ICI-DM remains to be elucidated. This case provides important insight into ICI-DM that develops after prolonged ICI administration, and it suggests that patients should be monitored for ICI-DM regardless of the duration of ICI therapy.
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Affiliation(s)
- Yuma Motomura
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shin Urai
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Diabetes and Endocrinology, Hyogo Cancer Center, Akashi, Japan
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Takegawa
- Department of Gastroenterological Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Masahiro Tsuda
- Department of Gastroenterological Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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23
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Guitton R, Lambotte O, Chiche L. [Managing cancer immunotherapy toxicities: Challenges and rechallenges for (young) internists]. Rev Med Interne 2024; 45:1-5. [PMID: 38158294 DOI: 10.1016/j.revmed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Affiliation(s)
- R Guitton
- Amicale des jeunes internistes, 15, rue de l'École-de-Médecine, 75005 Paris, France; Service de médecine interne et immunologie clinique, CHRU de Nancy, Nancy, France
| | - O Lambotte
- Inserm, CEA, UMR1184, service de médecine interne immunologie clinique, université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - L Chiche
- Service de médecine interne, hôpital Européen, 6, rue Désirée-Clary, 13003 Marseille, France.
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24
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Fujiwara Y, Horita N, Adib E, Zhou S, Nassar AH, Asad ZUA, Cortellini A, Naqash AR. Treatment-related adverse events, including fatal toxicities, in patients with solid tumours receiving neoadjuvant and adjuvant immune checkpoint blockade: a systematic review and meta-analysis of randomised controlled trials. Lancet Oncol 2024; 25:62-75. [PMID: 38012893 DOI: 10.1016/s1470-2045(23)00524-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Incorporating immune checkpoint blockade into perioperative cancer therapy has improved clinical outcomes. However, the safety of immune checkpoint blockade needs better evaluation, given the chances of more prolonged disease-free survival. We aimed to assess how adding immune checkpoint blockade to perioperative therapy affects treatment-related adverse events. METHODS For this systematic review and meta-analysis, we searched PubMed/MEDLINE, Embase, Web of Science, and the Cochrane Library from database inception until Aug 8, 2023, for randomised controlled trials that assessed the addition of immune checkpoint blockade to neoadjuvant or adjuvant therapy for cancer, reported treatment-related deaths, and had a design in which the experimental group assessed immune checkpoint blockade in combination with the therapy used in the control group. Meta-analysis was done to pool odds ratios (ORs) of treatment-related deaths, any grade and grade 3-4 treatment-related adverse events, serious adverse events, and adverse events leading to treatment discontinuation. The protocol is registered with PROSPERO, CRD42022343741. FINDINGS 28 randomised controlled trials with 16 976 patients were included. The addition of immune checkpoint blockade was not significantly associated with increased treatment-related deaths (OR 1·76, 95% CI 0·95-3·25; p=0·073), consistent across immune checkpoint blockade subtype (I2=0%). 40 fatal toxicities were identified across 9864 patients treated with immune checkpoint blockade, with pneumonitis being the most common (six [15·0%]); 13 fatal toxicities occurred among 7112 patients who were not treated with immune checkpoint blockade. The addition of immune checkpoint blockade increased the incidence of grade 3-4 treatment-related adverse events (OR 2·73, 95% CI 1·98-3·76; p<0·0001), adverse events leading to treatment discontinuation (3·67, 2·45-5·51; p<0·0001), and treatment-related adverse events of any grade (2·60 [1·88-3·61], p<0·0001). The immune checkpoint blockade versus placebo design primarily used as adjuvant therapy was associated with increased incidence of treatment-related deaths (4·02, 1·04-15·63; p=0·044) and grade 3-4 adverse events (5·31, 3·08-9·15; p<0·0001), whereas the addition of immune checkpoint blockade in the neoadjuvant setting was not associated with increased incidence of treatment-related death (1·11, 95% CI 0·38-3·29; p=0·84) or grade 3-4 adverse events (1·17, 0·90-1·51; p=0·23). INTERPRETATION The addition of immune checkpoint blockade to perioperative therapy was associated with an increase in grade 3-4 treatment-related adverse events and adverse events leading to treatment discontinuation. These findings provide safety insights for further clinical trials assessing neoadjuvant or adjuvant immune checkpoint blockade therapy. Clinicians should closely monitor patients for treatment-related adverse events to prevent treatment discontinuations and morbidity from these therapies in earlier-stage settings. FUNDING None.
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Affiliation(s)
- Yu Fujiwara
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA; Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Nobuyuki Horita
- Chemotherapy Center, Yokohama City University Hospital, Kanazawa-ku, Yokohama, Japan
| | - Elio Adib
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Susu Zhou
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA
| | - Amin H Nassar
- Department of Hematology/Oncology, Yale New Haven Hospital, New Haven, CT, USA
| | - Zain Ul Abideen Asad
- Department of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Alessio Cortellini
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy; Department of Surgery and Cancer, Imperial College London, London, UK
| | - Abdul Rafeh Naqash
- Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA.
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25
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van Eijs MJM, Verheijden RJ, van der Wees SA, Nierkens S, van Lindert ASR, Suijkerbuijk KPM, van Wijk F. Toxicity-specific peripheral blood T and B cell dynamics in anti-PD-1 and combined immune checkpoint inhibition. Cancer Immunol Immunother 2023; 72:4049-4064. [PMID: 37794264 DOI: 10.1007/s00262-023-03541-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/03/2023] [Indexed: 10/06/2023]
Abstract
Immune checkpoint inhibitors (ICI) have revolutionized the treatment landscape of advanced malignancies, but come with a diverse spectrum of immune-related adverse events (irAEs). Mechanistic studies can aid the transition from expert-opinion to evidence-based irAE treatment strategies. We aimed to longitudinally characterize peripheral blood T and B cell dynamics in ICI-treated patients by multicolor flow cytometry and serum multiplex immunoassay at baseline, ± 3 weeks and ± 6 weeks or upon clinically relevant irAEs. We analyzed samples from 44 ICI-treated patients (24 anti-PD-1 monotherapy, 20 combined anti-PD-1/anti-CTLA-4; cICI), of whom 21 developed irAEs, and 10 healthy donors. IrAEs after cICI were characterized by significantly enhanced proliferation of Th1-associated, mainly (CD4+) CD27- effector memory T cells, as well as Th17-associated immune responses and germinal center activation (reflected by CXCL13 and IL-21 increases). We observed no changes in CD21lo, memory, class-switched or newly activated B cell subsets. Particularly double-positive PD-1+LAG-3+ CD8+ T cells showed enhanced cytotoxic capacity in patients with irAEs after cICI. Within anti-PD-1 monotherapy, irAEs were associated with modestly enhanced Th1-associated responses reflected by increased serum CXCL9 and CXCL10. In conclusion, ICI-induced toxicity is dominated by enhanced Th1-associated responses, but in cICI we also found evidence for Th17-associated responses and germinal center activation. Together, our data add to the growing body of evidence that irAEs may be driven by newly activated CD4+ helper T cells, specifically after cICI. This study also supports tailored irAE treatment, based on ICI regimen, and to deploy specific strategies such as Th17 inhibition especially in cICI-associated irAEs.
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Affiliation(s)
- Mick J M van Eijs
- Department of Medical Oncology, University Medical Center Utrecht, KC.02.085.2, P.O. Box 85090, 3508 AB, Utrecht, the Netherlands.
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Rik J Verheijden
- Department of Medical Oncology, University Medical Center Utrecht, KC.02.085.2, P.O. Box 85090, 3508 AB, Utrecht, the Netherlands
| | - Stefanie A van der Wees
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stefan Nierkens
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Anne S R van Lindert
- Department of Pulmonology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Karijn P M Suijkerbuijk
- Department of Medical Oncology, University Medical Center Utrecht, KC.02.085.2, P.O. Box 85090, 3508 AB, Utrecht, the Netherlands
| | - Femke van Wijk
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
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26
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Ladouceur A, Barnetche T, Mouterde G, Tison A, Bitoun S, Prey S, Dutriaux C, Gerard E, Pham-Ledard A, Beylot-Barry M, Zysman M, Veillon R, Domblides C, Daste A, Gross-Goupil M, Sionneau B, Lefort F, Larroquette M, Richez C, Truchetet ME, Schaeverbeke T, Kostine M. Immune checkpoint inhibitor rechallenge in patients who previously experienced immune-related inflammatory arthritis: a multicentre observational study. RMD Open 2023; 9:e003795. [PMID: 38030233 PMCID: PMC10689372 DOI: 10.1136/rmdopen-2023-003795] [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: 10/07/2023] [Accepted: 11/02/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE Another course of immune checkpoint inhibitors (ICIs) is often considered in patients with cancer progression and previous immune-related adverse events, including inflammatory arthritis (ICI-IA), but there are limited data regarding safety of ICI rechallenge in this setting. We aimed to assess the rate and clinical features associated with ICI-IA flare/recurrence on ICI rechallenge. METHODS We conducted a multicentre observational study including cancer patients with ICI-IA who started a second course of ICI more than 3 months after ICI discontinuation in four French university hospitals. Primary outcome was the frequency of ICI flare/recurrence after ICI rechallenge. RESULTS Twenty-three patients were included. At the time of ICI rechallenge, 18 patients reported no symptoms of ICI-IA (78%) and 5 had grade 1 (22%), 11 patients (48%) were not receiving any ICI-IA treatment, 11 (48%) were still on prednisone, 2 (9%) were on conventional synthetic disease-modifying antirheumatic drugs and 1 (4%) on anti-IL-6. ICI-IA flare/recurrence occurred in 12 patients (52%) with a median time of 1 month after ICI rechallenge. ICI-IA phenotype, disease activity and ICI-IA treatment at the time of ICI rechallenge did not differ according to ICI-IA flare/recurrence status. CONCLUSION In this first observational study of ICI-IA patients rechallenged with ICI, about half of the patients experienced ICI-IA flare/recurrence with a similar phenotype but occurring earlier than the initial ICI-IA, warranting close monitoring during the first month of retreatment. Risk of flare did not differ according to baseline immunosuppressive treatment at the time of rechallenge.
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Affiliation(s)
- Alexandra Ladouceur
- Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
- Rheumatology, McGill University Faculty of Medicine, Montreal, Quebec, Canada
| | - Thomas Barnetche
- Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
| | - Gael Mouterde
- Rheumatology, Hôpital Lapeyronie, Montpellier, France
| | | | - Samuel Bitoun
- Rheumatology, Université Paris Saclay, Hôpital Bicetre, Assistance Publique-Hôpitaux de Paris, FHU CARE, Le Kremlin-Bicetre, France
| | - Sorilla Prey
- Dermatology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Pediatric Dermatology Unit, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Caroline Dutriaux
- Dermatology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Emilie Gerard
- Dermatology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Anne Pham-Ledard
- Dermatology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Marie Beylot-Barry
- Dermatology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Maeva Zysman
- Pulmonology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Rémi Veillon
- Pulmonology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | - Amaury Daste
- Oncology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | - Baptiste Sionneau
- Oncology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Felix Lefort
- Oncology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | - Christophe Richez
- Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
- UMR CNRS 5164, Université de Bordeaux Collège Sciences de la Santé, Bordeaux, France
| | - Marie-Elise Truchetet
- Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
| | - Thierry Schaeverbeke
- Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
| | - Marie Kostine
- Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
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27
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Alouani E, Laparra A, Perret A, Sakkal M, Messayke S, Danlos FX, Ouali K, Hollebecque A, Even C, Ammari S, Baldini C, Champiat S, Besse B, Robert C, Guettier C, Samuel D, Lambotte O, De Martin E, Michot JM. Immunosuppressant mycophenolate mofetil for patients with steroid-refractory immune-related hepatitis induced by checkpoint inhibitors in oncology. Eur J Cancer 2023; 193:113313. [PMID: 37748398 DOI: 10.1016/j.ejca.2023.113313] [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: 06/25/2023] [Revised: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Immune-checkpoint inhibitor (ICI) hepatitis, which does not improve with steroids and requires additional immunosuppressant, is defined as steroid-refractory ICI hepatitis. The outcome of patients with steroid-refractory ICI hepatitis remains poorly determined. Herein, we investigated the incidence, clinical features, and outcome of patients treated with second-line immunosuppressant for steroid-refractory ICI hepatitis. METHODS This is a retrospective analysis of patients who presented ICI hepatitis from 1st June 2016 to 30th September 2022. Steroid-refractory ICI hepatitis was defined as no clinical and biological improvement after systemic steroid therapy ≥1 mg/kg/d. Main objectives were to assess the frequency and risk factors associated with steroid-refractory ICI hepatitis and to evaluate the efficacy of second-line immunosuppressants. RESULTS In total, 130 patients with grade ≥3 ICI hepatitis were screened, of them 60 (46.2%) were treated with systemic steroids. In total, 11/130 (8.5%) had steroid-refractory hepatitis. Statistically significant factors associated with steroid-refractory hepatitis included previous liver comorbidities (54.5% versus 11.6%; p < 0.01), hyperbilirubinemia (p < 0.001), and general symptoms (fever, jaundice, ascites, and/or encephalopathy) associated with hepatitis (72.7% versus 30.8%; p = 0.015). The 11 patients with steroid-refractory hepatitis were treated with mycophenolate mofetil. In total, resolution or return to grade ≤1 for hepatitis was observed in 81.8% (9/11) of patients. CONCLUSIONS Steroid-refractory ICI hepatitis accounted for 8.5% of patients with grade ≥3 immune-related hepatitis and was statistically associated with previous liver comorbidities, hyperbilirubinemia, and general symptoms. Mycophenolate mofetil was a suitable option of therapy for steroid-refractory ICI hepatitis.
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Affiliation(s)
- Emily Alouani
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; Digestive Medical Oncology Department, IUCT-Rangueil, Toulouse Hospital University, Toulouse, France
| | - Ariane Laparra
- Département Interdisciplinaire d'Organisation des Parcours Patients, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Audrey Perret
- Département Interdisciplinaire d'Organisation des Parcours Patients, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Madonna Sakkal
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Sabine Messayke
- Pharmacovigilance Unit, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Francois-Xavier Danlos
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; INSERM U1015 and CIC1428 BIOTHERIS, Gustave Roussy, Villejuif, France
| | - Kaissa Ouali
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Antoine Hollebecque
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Caroline Even
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Samy Ammari
- ELSAN Department of Radiology, Institut de Cancérologie Paris Nord, Sarcelles, France; Department of Radiology, Gustave Roussy Cancer Campus, Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, Villejuif, France
| | - Capucine Baldini
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Stéphane Champiat
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Benjamin Besse
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Caroline Robert
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Catherine Guettier
- Department of Pathology, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Paris-Saclay University, UMR-S 1193, Le Kremlin Bicêtre, France
| | - Didier Samuel
- Department of Hepatology, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Centre Hépato-Biliaire, INSERM 1193, Villejuif, France
| | - Olivier Lambotte
- Internal Médecine Department, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Paris-Saclay University, Le Kremlin-Bicêtre, France; IDMIT Department, IBFJ, Centre Immunology of Viral Infections and Autoimmune Diseases, INSERM, CEA, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Eleonora De Martin
- Department of Hepatology, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Centre Hépato-Biliaire, INSERM 1193, Villejuif, France
| | - Jean-Marie Michot
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; INSERM U1170, Université Paris-Saclay, Gustave Roussy, Villejuif, France.
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28
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Kumar V, Wei XX. Immune Checkpoint Inhibitors in Metastatic Bladder and Other Solid Malignancies: How Long is Enough? Bladder Cancer 2023; 9:201-210. [PMID: 38993185 PMCID: PMC11181755 DOI: 10.3233/blc-230039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/24/2023] [Indexed: 07/13/2024]
Abstract
The introduction of T-cell targeted immunomodulators blocking the PD-1 and PD-L1 axis is unquestionably one of the most notable advancements in the treatment of advanced or metastatic solid malignancies, including bladder cancer. Immune checkpoint antibodies are now widely utilized as monotherapies or in combination with other systemic therapies in the first or subsequent lines of treatment in approximately 50 cancer types. Deep and durable responses and long tails of survival curves are hallmarks of patients treated with immune checkpoint inhibitors. However, treatment can have negative impacts, including serious treatment-related side effects as well as a high financial burden to individual patients and the healthcare system. There is increasing data that the benefit of immune checkpoint treatment may persist after treatment is discontinued for reasons other than progressive disease, particularly in patients who have achieved a durable complete response. However, the optimal treatment duration and activity after treatment reinitiation remains undefined and will likely be influenced by disease biology (histology and genomics), treatment (monotherapy or combination therapy), and disease context (depth and duration of response). Well-designed prospective clinical trials and the development and validation of biomarkers that predict outcomes after treatment cessation are needed to move the field forward.
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Affiliation(s)
- Vivek Kumar
- Brigham and Women’s Hospital, Boston, MA, USA
| | - Xiao X. Wei
- Dana-Farber Cancer Institute, Boston, MA, USA
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29
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Saad ED, Coart E, Deltuvaite-Thomas V, Garcia-Barrado L, Burzykowski T, Buyse M. Trial Design for Cancer Immunotherapy: A Methodological Toolkit. Cancers (Basel) 2023; 15:4669. [PMID: 37760636 PMCID: PMC10527464 DOI: 10.3390/cancers15184669] [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: 06/12/2023] [Revised: 08/12/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Immunotherapy with checkpoint inhibitors (CPIs) and cell-based products has revolutionized the treatment of various solid tumors and hematologic malignancies. These agents have shown unprecedented response rates and long-term benefits in various settings. These clinical advances have also pointed to the need for new or adapted approaches to trial design and assessment of efficacy and safety, both in the early and late phases of drug development. Some of the conventional statistical methods and endpoints used in other areas of oncology appear to be less appropriate in immuno-oncology. Conversely, other methods and endpoints have emerged as alternatives. In this article, we discuss issues related to trial design in the early and late phases of drug development in immuno-oncology, with a focus on CPIs. For early trials, we review the most salient issues related to dose escalation, use and limitations of tumor response and progression criteria for immunotherapy, the role of duration of response as an endpoint in and of itself, and the need to conduct randomized trials as early as possible in the development of new therapies. For late phases, we discuss the choice of primary endpoints for randomized trials, review the current status of surrogate endpoints, and discuss specific statistical issues related to immunotherapy, including non-proportional hazards in the assessment of time-to-event endpoints, alternatives to the Cox model in these settings, and the method of generalized pairwise comparisons, which can provide a patient-centric assessment of clinical benefit and be used to design randomized trials.
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Affiliation(s)
- Everardo D. Saad
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
| | - Elisabeth Coart
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
| | - Vaiva Deltuvaite-Thomas
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
| | - Leandro Garcia-Barrado
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
| | - Tomasz Burzykowski
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), Hasselt University, B-3500 Hasselt, Belgium
| | - Marc Buyse
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), Hasselt University, B-3500 Hasselt, Belgium
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30
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Liu M, Christ L, Richters A, Özdemir BC. Toxicity, disease management and outcome of treatment with immune checkpoint inhibitors by sex in patients with cancer and preexisting autoimmune disease. Oncol Lett 2023; 26:377. [PMID: 37559593 PMCID: PMC10407854 DOI: 10.3892/ol.2023.13963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/09/2023] [Indexed: 08/11/2023] Open
Abstract
Female sex is associated with a higher risk for autoimmune diseases (ADs) and immune-related adverse events (irAEs) from immune checkpoint inhibitors (ICIs). While the safety of ICIs in AD cohorts has been reported, sex-segregated data on patient characteristics and outcomes are lacking. In the present study, the disease and treatment characteristics of 51 patients with cancer and preexisting AD (PAD) treated with ICIs at Bern University Hospital Cancer Center (Bern, Switzerland) between January 2017 and June 2021 were analyzed by sex. Rheumatic (n=12/27, 44.4%) and endocrine (n=11/24, 45.8%) PADs were most common among male and female patients, respectively. At the time of ICI initiation, 29.6% (n=8/27) of male and 20.8% (n=5/24) of female patients received immunosuppression for their PAD. Female patients were more likely to experience an irAE (58.3 vs. 48.1%), and less likely to encounter an exacerbation of their PAD (38.5 vs. 14.3%) compared with male patients. Multiple-site irAEs (46.2 vs. 21.4%), implication of an organ specialist for irAEs (100.0 vs. 57.1%) and use of additional immunosuppressive drugs (38.4 vs. 7.7%) were more common in male patients. IrAEs were resolved and ICIs were discontinued in 69.2% (n=9/13) and 71.4% (n=10/14) of the total male and female patients, respectively. Median progression-free survival was higher in male than female patients with irAEs (19.9 vs. 10.7 months) and without irAEs (4.4 vs. 1.8 months). The median overall survival time was higher in male than female patients with irAEs (not estimable vs. 22.5 months) and without irAEs (10.1 vs. 7.4 months). Taken together, these results suggested that sex-related differences existed regarding the clinical presentation of irAEs and treatment outcome.
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Affiliation(s)
- Michael Liu
- Department of Medical Oncology, Inselspital Bern, Bern University Hospital, University of Bern, CH-3011 Bern, Switzerland
| | - Lisa Christ
- Department of Rheumatology and Immunology, Inselspital Bern, Bern University Hospital, University of Bern, CH-3011 Bern, Switzerland
| | - Anke Richters
- Department of Research and Development, The Netherlands Comprehensive Cancer Organisation, 3511 DT Utrecht, The Netherlands
- Radboud University Medical Center, Radboud Institute for Health Sciences, 6525 GA Nijmegen, The Netherlands
| | - Berna C. Özdemir
- Department of Medical Oncology, Inselspital Bern, Bern University Hospital, University of Bern, CH-3011 Bern, Switzerland
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31
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Gao J, Zhang C, Wei Z, Ye X. Immunotherapy for early-stage non-small cell lung cancer: A system review. J Cancer Res Ther 2023; 19:849-865. [PMID: 37675709 DOI: 10.4103/jcrt.jcrt_723_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
With the addition of immunotherapy, lung cancer, one of the most common cancers with high mortality rates, has broadened the treatment landscape. Immune checkpoint inhibitors have demonstrated significant efficacy in the treatment of non-small cell lung cancer (NSCLC) and are now used as the first-line therapy for metastatic disease, consolidation therapy after radiotherapy for unresectable locally advanced disease, and adjuvant therapy after surgical resection and chemotherapy for resectable disease. The use of adjuvant and neoadjuvant immunotherapy in patients with early-stage NSCLC, however, is still debatable. We will address several aspects, namely the initial efficacy of monotherapy, the efficacy of combination chemotherapy, immunotherapy-related biomarkers, adverse effects, ongoing randomized controlled trials, and current issues and future directions for immunotherapy in early-stage NSCLC will be discussed here.
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Affiliation(s)
- Jingyi Gao
- Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong; Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, China
| | - Chao Zhang
- Department of Oncology, Affiliated Qujing Hospital of Kunming Medical University, QuJing, Yunnan Province, China
| | - Zhigang Wei
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, China
| | - Xin Ye
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, China
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32
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Barron CC, Stefanova I, Cha Y, Elsolh K, Zereshkian A, Gaafour N, McWhirter E. Chronic immune-related adverse events in patients with cancer receiving immune checkpoint inhibitors: a systematic review. J Immunother Cancer 2023; 11:e006500. [PMID: 37536939 PMCID: PMC10401216 DOI: 10.1136/jitc-2022-006500] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/05/2023] Open
Abstract
Immune-related adverse events (irAEs) are toxicities resulting from use of immune checkpoint inhibitors (ICIs). These side effects persist in some patients despite withholding therapy and using immunosuppressive and immune-modulating agents. Little is known about chronic irAEs and they are felt to be rare. We performed a systematic review to characterize non-endocrine chronic irAEs reported in the literature and describe their management. Ovid MEDLINE and Embase databases were searched for reports of adult patients with solid cancers treated with ICIs who experienced chronic (>12 weeks) non-endocrine irAEs. Patient, treatment and toxicity data were collected. Of 6843 articles identified, 229 studies including 323 patients met our inclusion criteria. The median age was 65 (IQR 56-72) and 58% were male. Most patients (75%) had metastatic disease and the primary cancer site was melanoma in 43% and non-small cell lung cancer in 31% of patients. The most common ICIs delivered were pembrolizumab (24%) and nivolumab (37%). The chronic irAEs experienced were rheumatological in 20% of patients, followed by neurological in 19%, gastrointestinal in 16% and dermatological in 14%. The irAE persisted for a median (range) of 180 (84-2370) days and 30% of patients had ongoing symptoms or treatment. More than half (52%) of patients had chronic irAEs that persisted for >6 months. The ICI was permanently discontinued in 60% of patients and 76% required oral and/or intravenous steroids. This is the first systematic review to assess and report on moderate/severe chronic non-endocrine irAEs after treatment with ICI in the literature. These toxicities persisted for months-years and the majority required discontinuation of therapy and initiation of immunosuppression. Further research is needed to better understand chronic irAEs, which hold potential substantial clinical significance considering the expanded use of ICIs and their integration into the (neo)adjuvant settings.
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Affiliation(s)
- Carly C Barron
- Department of Medical Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Yevin Cha
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karam Elsolh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Arman Zereshkian
- Department of Medical Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nessma Gaafour
- Alexandria University Faculty of Science, Alexandria, Egypt
| | - Elaine McWhirter
- Department of Medical Oncology, Juravinski Cancer Centre, Hamilton, Ontario, Canada
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33
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Ascierto PA, Agarwala SS, Warner AB, Ernstoff MS, Fox BA, Gajewski TF, Galon J, Garbe C, Gastman BR, Gershenwald JE, Kalinski P, Krogsgaard M, Leidner RS, Lo RS, Menzies AM, Michielin O, Poulikakos PI, Weber JS, Caracò C, Osman I, Puzanov I, Thurin M. Perspectives in Melanoma: meeting report from the Melanoma Bridge (December 1st-3rd, 2022-Naples, Italy). J Transl Med 2023; 21:508. [PMID: 37507765 PMCID: PMC10375730 DOI: 10.1186/s12967-023-04325-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/01/2023] [Indexed: 07/30/2023] Open
Abstract
Outcomes for patients with melanoma have improved over the past decade with the clinical development and approval of immunotherapies targeting immune checkpoint receptors such as programmed death-1 (PD-1), programmed death ligand 1 (PD-L1) or cytotoxic T lymphocyte antigen-4 (CTLA-4). Combinations of these checkpoint therapies with other agents are now being explored to improve outcomes and enhance benefit-risk profiles of treatment. Alternative inhibitory receptors have been identified that may be targeted for anti-tumor immune therapy, such as lymphocyte-activation gene-3 (LAG-3), as have several potential target oncogenes for molecularly targeted therapy, such as tyrosine kinase inhibitors. Unfortunately, many patients still progress and acquire resistance to immunotherapy and molecularly targeted therapies. To bypass resistance, combination treatment with immunotherapies and single or multiple TKIs have been shown to improve prognosis compared to monotherapy. The number of new combinations treatment under development for melanoma provides options for the number of patients to achieve a therapeutic benefit. Many diagnostic and prognostic assays have begun to show clinical applicability providing additional tools to optimize and individualize treatments. However, the question on the optimal algorithm of first- and later-line therapies and the search for biomarkers to guide these decisions are still under investigation. This year, the Melanoma Bridge Congress (Dec 1st-3rd, 2022, Naples, Italy) addressed the latest advances in melanoma research, focusing on themes of paramount importance for melanoma prevention, diagnosis and treatment. This included sessions dedicated to systems biology on immunotherapy, immunogenicity and gene expression profiling, biomarkers, and combination treatment strategies.
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Affiliation(s)
- Paolo A Ascierto
- Department of Melanoma, Cancer Immunotherapy and Innovative Therapy, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy.
| | | | | | - Marc S Ernstoff
- ImmunoOncology Branch (IOB), Developmental Therapeutics Program, Cancer Therapy and Diagnosis Division, National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Bernard A Fox
- Robert W. Franz Cancer Center, Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, OR, USA
| | - Thomas F Gajewski
- Department of Pathology and Department of Medicine (Section of Hematology/Oncology), University of Chicago, Chicago, IL, USA
| | - Jérôme Galon
- INSERM, Laboratory of Integrative Cancer Immunology, 75006, Paris, France
- Centre de Recherche Des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - Brian R Gastman
- Department of Surgery, School of Medicine, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pawel Kalinski
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Michelle Krogsgaard
- Laura and Isaac Perlmutter Cancer Center and Department of Pathology, New York University Grossman School of Medicine, New York, NY, USA
| | - Rom S Leidner
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, OR, USA
| | - Roger S Lo
- Jonsson Comprehensive Cancer Center David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Olivier Michielin
- Department of Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Poulikos I Poulikakos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey S Weber
- Laura and Isaac Perlmutter Cancer Center, a NCI-Funded Comprehensive Cancer Center, NYU School of Medicine, New York, NY, USA
| | - Corrado Caracò
- Division of Surgery of Melanoma and Skin Cancer, Istituto Nazionale Tumori "Fondazione Pascale" IRCCS, Naples, Italy
| | - Iman Osman
- Rudolf L, Baer, New York University Langone Medical Center, New York, NY, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Magdalena Thurin
- Division of Cancer Treatment and Diagnosis, National Cancer Institute (NCI), National Institute of Health (NIH), Bethesda, MD, USA
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