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Pasoto SG, Franco AS, Silva CA, Bonfa E. Sicca syndrome/Sjögren's disease associated with cancer immunotherapy: a narrative review on clinical presentation, biomarkers, and management. Expert Rev Clin Immunol 2024:1-19. [PMID: 38903050 DOI: 10.1080/1744666x.2024.2370327] [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: 03/17/2024] [Accepted: 06/17/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION Almost one-quarter of immune checkpoint inhibitor (ICI) recipients experience sicca syndrome, while Sjögren's disease (SjD) is estimated at 0.3-2.5%, possibly underreported. AREAS COVERED This narrative review (Medline/Embase until January/31/2024) addresses the pathophysiology, incidence, demographic/clinical features, biomarkers, labial salivary gland biopsy (LSGB), fulfillment of the idiopathic SjD (iSjD) classificatory criteria, differential diagnosis, and management of sicca syndrome/SjD associated with ICIs. EXPERT OPINION SjD associated with ICIs is underdiagnosed, since studies that performed the mandatory SjD investigation identified that 40-60% of patients with sicca syndrome associated with ICIs meet the iSjD classificatory criteria. LSGB played a fundamental role in recognizing these cases, as most of them had negative anti-Ro/SS-A antibody. Despite the finding of focal lymphocytic sialoadenitis in LSGB samples mimicking iSjD, immunohistochemical analysis provided novel evidence of a distinct pattern for sicca syndrome/SjD associated with ICIs compared to iSjD. The former has scarcity of B lymphocytes, which are a hallmark of iSjD. Additionally, patients with sicca syndrome/SjD associated with ICIs have demographical/clinical/serological and treatment response dissimilarities compared to iSjD. Dryness symptoms are more acute in the former than in iSjD, with predominance of xerostomia over xerophthalmia, and partial/complete response to glucocorticoids. Dryness symptoms in ICI-treated patients warrant prompt SjD investigation.
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Affiliation(s)
- Sandra Gofinet Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - André Silva Franco
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Clovis Artur Silva
- Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Eloisa Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
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Ruf T, Kramer R, Forschner A, Leiter U, Meier F, Reinhardt L, Dücker P, Ertl C, Tomsitz D, Tietze JK, Gutzmer R, Dabrowski E, Zimmer L, Gesierich A, Zierold S, French LE, Eigentler T, Amaral T, Heinzerling L. Second-line therapies for steroid-refractory immune-related adverse events in patients treated with immune checkpoint inhibitors. Eur J Cancer 2024; 203:114028. [PMID: 38652976 DOI: 10.1016/j.ejca.2024.114028] [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: 01/10/2024] [Revised: 03/03/2024] [Accepted: 03/12/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) induce adverse events (irAEs) that do not respond to steroids, i.e. steroid-refractory (sr) irAEs, and irAEs in which steroids cannot be tapered, i.e. steroid-dependent (sd) irAEs, in about 10% of cases. An evidence-based analysis of the effectiveness of second-line immunosuppressive agents with regard to irAE and tumor control is lacking. METHODS The international web-based Side Effect Registry Immuno-Oncology (SERIO; http://serio-registry.org) is a collaborative initiative with the Paul-Ehrlich-Institute to document rare, severe, complex or therapy-refractory immunotherapy-induced side effects. The registry was queried on August 1, 2023 for cases of irAEs which were treated with second-line therapies. RESULTS From a total of 1330 cases, 217 patients (16.3%) received 249 second-line therapies. A total of 19 different second-line therapies were employed, including TNF-alpha antagonists (46.5%), intravenous immunoglobulins (IVIG; 19.1%), mycophenolate mofetil (15.9%), and methotrexate (3.6%). Therapy choices were determined by the type of irAE. The time to onset of sr-/sd-irAEs after ICI initiation did not consistently differ from steroid-responsive irAEs. While 74.3% of sr-/sd-irAEs resolved and 13.1% had improved, 4.3% persisted, 3.9% resulted in permanent sequelae, and 4.3% in death with ongoing symptoms. Infliximab exhibited potential for earlier symptom improvement compared to mycophenolate mofetil or IVIG. Tumor response in patients with second-line treated sd-/sr-irAE was similar to patients with irAEs treated with steroids only. CONCLUSION Several second-line therapies are effective against sr-/sd-irAEs, the second-line therapies show no clear negative impact on tumor response, and infliximab shows potential for faster improvement of symptoms. However, prospective comparative data are needed.
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Affiliation(s)
- Theresa Ruf
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany; SERIO registry
| | - Rafaela Kramer
- Department of Dermatology, University Clinic Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany; SERIO registry
| | - Andrea Forschner
- Department of Dermatology, Eberhard-Karls-University of Tübingen, Tübingen, Germany
| | - Ulrike Leiter
- Department of Dermatology, Eberhard-Karls-University of Tübingen, Tübingen, Germany
| | - Friedegund Meier
- Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Lydia Reinhardt
- Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Pia Dücker
- Department of Dermatology, Hospital Dortmund, Dortmund, Germany
| | - Carolin Ertl
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany; SERIO registry
| | - Dirk Tomsitz
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - Julia K Tietze
- Clinic for Dermatology and Venerology, University Medical Center Rostock, Rostock, Germany
| | - Ralf Gutzmer
- Department of Dermatology, Johannes Wesling Medical Center, Ruhr-University Bochum, Minden, Germany
| | | | - Lisa Zimmer
- Department of Dermatology, Essen University Hospital, West German Cancer Center, University of Duisburg-Essen and the German Cancer Consortium (DKTK), Partner site Essen/Düsseldorf, Germany
| | - Anja Gesierich
- Department of Dermatology, University Hospital Würzburg, Germany
| | - Sarah Zierold
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany; SERIO registry
| | - Lars E French
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany; Dr. Philip Frost Department of Dermatology & Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Thomas Eigentler
- Department of Dermatology, Charité University Medicine Berlin, Berlin, Germany
| | - Teresa Amaral
- Department of Dermatology, Eberhard-Karls-University of Tübingen, Tübingen, Germany; Cluster of Excellence iFIT (EXC 2180), Tübingen, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany; Department of Dermatology, University Clinic Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany; SERIO registry.
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Ladouceur A, Ezdoglian A, Sparks JA, Hudson M, Jamal S, Clifford A, Roberts J, Ye C. The Utility of Laboratory Investigations for the Assessment and Management of Rheumatic Immune Related Adverse Events. Rheum Dis Clin North Am 2024; 50:181-199. [PMID: 38670720 DOI: 10.1016/j.rdc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have greatly improved survival of several cancers with historically very poor prognosis. ICIs act by stimulating the patient's own immune system to fight cancer. Simultaneously, this immune activation can lead to immune-related adverse events (irAEs), including rheumatic manifestations (Rh-irAEs). Rh-irAEs mimic primary rheumatic diseases including arthritis, polymyalgia rheumatica, myositis, vasculitis, sarcoidosis, and sicca. This article summarizes the latest evidence regarding the utility of laboratory investigations in Rh-irAEs.
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Affiliation(s)
- Alexandra Ladouceur
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - Aiarpi Ezdoglian
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, VU University Medical Center (VUmc), De Boelelaan 1118, Amsterdam 1081 HZ, the Netherlands
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Suite 6016U, Boston, MA 02115, USA
| | - Marie Hudson
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, Lady Davis Institute for Medical Research, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - Shahin Jamal
- Arthritis Research Canada, Department of Medicine, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel Street, Ste 8205B, Vancouver, British Columbia V5Z 1M9, Canada
| | - Alison Clifford
- Faculty of Medicine & Dentistry, Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, Alberta T6G 2G3, Canada
| | - Janet Roberts
- Division of Rheumatology, Department of Medicine, Queen Elizabeth II Health Sciences Center and Dalhousie University, Nova Scotia rehabilitation and Arthritis Centre, Arthritis Research Canada; Lady Davis Institute for Medical Research, 1341 Summer Street, Halifax, Nova Scotia B3H 4K4, Canada
| | - Carrie Ye
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, Alberta T6G 2G3, Canada.
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Singh N, Shahane A, Sparks JA, Bitoun S, Cappelli LC. Immune Checkpoint Inhibitor-induced Inflammatory Arthritis: Current Approaches to Management. Rheum Dis Clin North Am 2024; 50:269-279. [PMID: 38670725 PMCID: PMC11139458 DOI: 10.1016/j.rdc.2024.02.002] [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] [Indexed: 04/28/2024]
Abstract
The introduction of immune checkpoint inhibitors (ICIs) has changed the landscape of the treatment of cancer. Several immune-related adverse events (irAEs) have now been described such as ICI-inflammatory arthritis (IA), sicca syndrome, polymyalgia rheumatica, myositis, and vasculitis as a consequence of immune activation. The onset of the ICI-IA can vary from after the first infusion of ICIs to a delayed presentation a year or more after ICI initiation. Ultimately, baseline patient and tumor characteristics, the types of immunotherapies used, pre-existing autoimmune diseases, and/or other irAEs, as well as patient preferences will all shape the discussions around ICI-IA management.
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Affiliation(s)
- Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington, 4245 Roosevelt Way Northeast, Seattle, WA 98105, USA
| | - Anupama Shahane
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, 220 South 40th Street, Philadelphia, PA 19104, USA
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, 12 Braddock Park, Unit 2, Boston, MA 02116, USA
| | - Samuel Bitoun
- Department of Rheumatology, Université Paris-Saclay, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, FHU CARE, INSERM UMR1184, 78, Avenue du General Leclerc, Le Kremlin Bicêtre 94270, France
| | - Laura C Cappelli
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Suite 1B1, Baltimore, MD 21224, USA.
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5
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Zhang J, Ni R, Oke I, Calabrese C, Strouse J, Weinmann S, Ladouceur A. Imaging in Rheumatic Immune-related Adverse Events. Rheum Dis Clin North Am 2024; 50:313-323. [PMID: 38670729 DOI: 10.1016/j.rdc.2024.02.005] [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: 04/28/2024]
Abstract
Since their introduction, immune checkpoint inhibitors have revolutionized cancer treatment by harnessing the body's own immune system as a defense against tumor growth. The downside of activating the immune system is the development of immune-related adverse events (irAEs), which mimic autoimmune disease of various organ systems. The musculoskeletal system is an uncommon, but substantial one for patients and can lead to long-term pain and disability that affects their quality of life. This review summarizes recent literature on imaging forms utilized for diagnosis and assessing treatment response in rheumatic irAEs.
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Affiliation(s)
- Jeremy Zhang
- Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, C310 GH, Iowa City, IA 52242-1009, USA
| | - Ruoning Ni
- Division of Immunology, University of Iowa Carver College of Medicine, 200 Hawkins Drive, C42 GH, Iowa City, IA 52242-1009, USA
| | - Ibiyemi Oke
- Division of Immunology, University of Iowa Carver College of Medicine, 200 Hawkins Drive, C42 GH, Iowa City, IA 52242-1009, USA
| | - Cassandra Calabrese
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic, 9500 Euclid Avenue, Mail Code A50, Cleveland, OH 44195, USA
| | - Jennifer Strouse
- Division of Immunology, University of Iowa Carver College of Medicine, 200 Hawkins Drive, C42 GH, Iowa City, IA 52242-1009, USA
| | - Sophia Weinmann
- Division of Rheumatology & Immunology, Duke University School of Medicine, 40 Duke Medicine Circle, Clinic 1J, Durham, NC 27710, USA
| | - Alexandra Ladouceur
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, 3755 Côte Ste-Catherine Road, Room A725, Montreal, Quebec H3T 1E2, Canada.
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Harnden K, Di Matteo A, Howell K, Mankia K. Rapid onset pembrolizumab-induced inflammatory arthritis diagnosed using musculoskeletal ultrasound. BMJ Case Rep 2024; 17:e258706. [PMID: 38663895 PMCID: PMC11043772 DOI: 10.1136/bcr-2023-258706] [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: 04/28/2024] Open
Abstract
Immune checkpoint inhibitors have revolutionised the treatment of cancer. While very effective, they commonly cause a wide spectrum of immune-related adverse events. These immune-related adverse events can be fatal and often have significant effects on quality of life. They therefore require prompt recognition and management. We report the case of a woman presenting with widespread joint pain and stiffness 6 hours after her first pembrolizumab infusion. She had no joint swelling on physical examination but an ultrasound scan revealed widespread musculoskeletal inflammation, confirming the diagnosis of inflammatory arthritis. To the best of our knowledge, this is the fastest reported inflammatory arthritis onset following immune checkpoint inhibitor treatment. It highlights the importance of timely imaging in patients on immune checkpoint inhibitors who present with new non-specific musculoskeletal pain. Her symptoms improved dramatically with intramuscular triamcinolone injection.
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Affiliation(s)
- Kate Harnden
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
| | - Andrea Di Matteo
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Kulveer Mankia
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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7
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Deng D, Zhang T, Ma L, Zhao W, Huang S, Wang K, Shu S, Chen X. PD-L1/PD-1 pathway: a potential neuroimmune target for pain relief. Cell Biosci 2024; 14:51. [PMID: 38643205 PMCID: PMC11031890 DOI: 10.1186/s13578-024-01227-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 04/01/2024] [Indexed: 04/22/2024] Open
Abstract
Pain is a common symptom of many diseases with a high incidence rate. Clinically, drug treatment, as the main method to relieve pain at present, is often accompanied by different degrees of adverse reactions. Therefore, it is urgent to gain a profound understanding of the pain mechanisms in order to develop advantageous analgesic targets. The PD-L1/PD-1 pathway, an important inhibitory molecule in the immune system, has taken part in regulating neuroinflammation and immune response. Accumulating evidence indicates that the PD-L1/PD-1 pathway is aberrantly activated in various pain models. And blocking PD-L1/PD-1 pathway will aggravate pain behaviors. This review aims to summarize the emerging evidence on the role of the PD-L1/PD-1 pathway in alleviating pain and provide an overview of the mechanisms involved in pain resolution, including the regulation of macrophages, microglia, T cells, as well as nociceptor neurons. However, its underlying mechanism still needs to be further elucidated in the future. In conclusion, despite more deep researches are needed, these pioneering studies indicate that PD-L1/PD-1 may be a potential neuroimmune target for pain relief.
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Affiliation(s)
- Daling Deng
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
| | - Tianhao Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
| | - Lulin Ma
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
| | - Wenjing Zhao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
| | - Shiqian Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
| | - Kaixing Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
| | - Shaofang Shu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
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8
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Tran SD, Lin J, Galvez C, Rasmussen LV, Pacheco J, Perottino GM, Rahbari KJ, Miller CD, John JD, Theros J, Vogel K, Dinh PV, Malik S, Ramzan U, Tegtmeyer K, Mohindra N, Johnson JL, Luo Y, Kho A, Sosman J, Walunas TL. Rapid identification of inflammatory arthritis and associated adverse events following immune checkpoint therapy: a machine learning approach. Front Immunol 2024; 15:1331959. [PMID: 38558818 PMCID: PMC10978703 DOI: 10.3389/fimmu.2024.1331959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA) poses a major clinical challenge to ICI therapy for cancer, with 13% of cases halting ICI therapy and ICI-IA being difficult to identify for timely referral to a rheumatologist. The objective of this study was to rapidly identify ICI-IA patients in clinical data and assess associated immune-related adverse events (irAEs) and risk factors. Methods We conducted a retrospective study of the electronic health records (EHRs) of 89 patients who developed ICI-IA out of 2451 cancer patients who received ICI therapy at Northwestern University between March 2011 to January 2021. Logistic regression and random forest machine learning models were trained on all EHR diagnoses, labs, medications, and procedures to identify ICI-IA patients and EHR codes indicating ICI-IA. Multivariate logistic regression was then used to test associations between ICI-IA and cancer type, ICI regimen, and comorbid irAEs. Results Logistic regression and random forest models identified ICI-IA patients with accuracies of 0.79 and 0.80, respectively. Key EHR features from the random forest model included ICI-IA relevant features (joint pain, steroid prescription, rheumatoid factor tests) and features suggesting comorbid irAEs (thyroid function tests, pruritus, triamcinolone prescription). Compared to 871 adjudicated ICI patients who did not develop arthritis, ICI-IA patients had higher odds of developing cutaneous (odds ratio [OR]=2.66; 95% Confidence Interval [CI] 1.63-4.35), endocrine (OR=2.09; 95% CI 1.15-3.80), or gastrointestinal (OR=2.88; 95% CI 1.76-4.72) irAEs adjusting for demographics, cancer type, and ICI regimen. Melanoma (OR=1.99; 95% CI 1.08-3.65) and renal cell carcinoma (OR=2.03; 95% CI 1.06-3.84) patients were more likely to develop ICI-IA compared to lung cancer patients. Patients on nivolumab+ipilimumab were more likely to develop ICI-IA compared to patients on pembrolizumab (OR=1.86; 95% CI 1.01-3.43). Discussion Our machine learning models rapidly identified patients with ICI-IA in EHR data and elucidated clinical features indicative of comorbid irAEs. Patients with ICI-IA were significantly more likely to also develop cutaneous, endocrine, and gastrointestinal irAEs during their clinical course compared to ICI therapy patients without ICI-IA.
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Affiliation(s)
- Steven D. Tran
- Center for Health Information Partnerships, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jean Lin
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Carlos Galvez
- Hematology and Oncology, University of Illinois Health, Chicago, IL, United States
| | - Luke V. Rasmussen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jennifer Pacheco
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | | | - Kian J. Rahbari
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Charles D. Miller
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jordan D. John
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jonathan Theros
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Kelly Vogel
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Patrick V. Dinh
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Sara Malik
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Umar Ramzan
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Kyle Tegtmeyer
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Nisha Mohindra
- Department of Medicine, Division of Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
| | - Jodi L. Johnson
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
- Departments of Pathology and Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Abel Kho
- Center for Health Information Partnerships, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jeffrey Sosman
- Department of Medicine, Division of Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
| | - Theresa L. Walunas
- Center for Health Information Partnerships, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Zhao M, Mi L, Ji Y, He X, Gao Y, Hu Y, Xu K. Advances of autoimmune rheumatic diseases related to malignant tumors. Inflamm Res 2023; 72:1965-1979. [PMID: 37768354 PMCID: PMC10611618 DOI: 10.1007/s00011-023-01780-6] [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: 04/30/2023] [Revised: 07/30/2023] [Accepted: 08/04/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Malignant neoplasms are a well-recognized global public health concern, with significant impacts on human health and quality of life. The interplay between tumors and autoimmune rheumatic diseases is complex, and the resulting tumor-associated rheumatic diseases represent a rare and intricate group of conditions that occur in the context of malignant tumors. In addition, various rheumatic diseases can arise as a consequence of oncology treatment. These diseases present with intricate clinical manifestations and pathological features, often rendering them challenging to diagnose and impacting patients' quality of life. Despite this, they have yet to be fully recognized. METHODS This article presents a literature review of published original articles and review articles concerning paraneoplastic rheumatic syndromes and rheumatic diseases associated with cancer treatment. We conducted a comprehensive literature search in PubMed, Web of Science and Google Scholar databases, excluding duplicated and irrelevant studies. In cases of duplicated research, we selected articles with higher impact factors for the review. RESULTS This review focuses on the clinical features, diagnosis, and treatment of paraneoplastic rheumatic diseases, as well as the pathogenesis of these diseases. Additionally, we summarize the autoimmune rheumatic diseases associated with cancer treatment. Ultimately, the goal of this review is to enhance recognition and improve the management of autoimmune rheumatic diseases related to tumors.
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Affiliation(s)
- Miaomiao Zhao
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Liangyu Mi
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Yuli Ji
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Xiaoyao He
- Department of Statistics, School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Yanan Gao
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Yuting Hu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Ke Xu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China.
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10
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Zou D, Wang X, Sun Y, Wang X, Lu C, Wang A, Wang X, Yang Y. Arthralgia adverse events due to immune-checkpoint inhibitors for lung cancer patients: a systematic review and meta-analysis. Front Oncol 2023; 13:1258287. [PMID: 37841432 PMCID: PMC10576430 DOI: 10.3389/fonc.2023.1258287] [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: 07/13/2023] [Accepted: 08/10/2023] [Indexed: 10/17/2023] Open
Abstract
Background Immune agents targeting Programmed cell death-1 (PD-1) are a new type of cancer treatment drugs. By inhibiting the interaction between PD-1 and PD-L1, the ability of the immune system to attack tumor cells is enhanced. These immune preparations have shown significant efficacy in the treatment of various malignant tumors. However, like other drugs, immune preparations targeting PD-1 may also cause side effects, including arthralgia. Therefore, we conduct a meta-analysis to assess whether immune-checkpoint inhibitors targeting programmed cell death-1 in lung cancer patients will lead to arthralgia adverse events. Methods We conducted a comprehensive search across multiple databases, including PubMed, Medline (Ovid), Web of Science, Cochrane, Embase, Scopus, CKNI, Wang fang, VIP database, Sino Med, and Clinical Trails, to identify relevant studies. The search encompassed articles published up until June 20th, 2023. The primary outcome is adverse events about arthralgia and secondary outcomes are any other related with arthralgia. Data extraction was carried out by two independent individuals, and the Cochrane Risk of Bias tool version 2.0 was employed to assess the included studies. The systematic review and meta-analysis were conducted using RevMan 5.3 software. Results 12 studies are included in the meta-analysis. All included studies were determined to have a low risk of random sequence generation bias. The meta-analysis result showed that arthralgia RR = 1.11, 95% CI [0.88, 1.40], I2 = 56%, back pain RR = 1.86, 95% CI [1.07, 3.26], I2 = 84%, myalgia RR = 0.49, 95% CI [0.27, 0.88], I2 = 86% and muscular pain RR = 1.97, 95% CI [1.40, 2.77], I2 = 23%. Conclusion The use of targeted inhibitors may lead to an increased incidence of back pain, while potentially reducing the occurrence of myalgia. On the other hand, immune-checkpoint inhibitors targeting programmed cell death-1 in lung cancer patients may not cause arthralgia and muscular pain.
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Affiliation(s)
- Defang Zou
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Jiangsu Collaborative Innovation Center of Traditional Chinese Medicine (TCM) Prevention and Treatment of Tumor, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaoping Wang
- Department of Orthopedics, PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Yamin Sun
- Department of Anesthesiology, Third Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xi Wang
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Chang Lu
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Aiyun Wang
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Jiangsu Collaborative Innovation Center of Traditional Chinese Medicine (TCM) Prevention and Treatment of Tumor, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xia Wang
- Oncology Department, the Second Affiliated Hospital of Nanjing University of Chinese Medicine (Jiangsu Provincial Second Chinese Medicine Hospital), Nanjing, China
| | - Yan Yang
- China Science and Technology Development Center of Chinese Medicine, Beijing, China
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11
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Abstract
PURPOSE OF REVIEW Immune check point inhibitors (ICIs) are a unique class of cancer treatments that harness the body's innate antitumor response. Although these medications have transformed oncology care, they also lead to generalized immune activation that can result in toxicities across a spectrum of organ systems called immune-related adverse events. This article reviews the most common rheumatologic immune-related adverse events and their management. RECENT FINDINGS Inflammatory arthritis, polymyalgia rheumatic, sicca symptoms, systemic sclerosis, myositis, and vasculitis have all been reported as ICI adverse events. Treatment includes nonsteroidal anti-inflammatory drugs, glucocorticoids, traditional DMARDs, and biologics. SUMMARY Rheumatologists have an important role in the management of patients with rheumatologic immune-related adverse events. Working with our oncology colleagues, we can help manage rheumatologic immune-related adverse events while optimally preserving ICI's antitumor effects.
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Affiliation(s)
- Melissa Defoe
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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12
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Ceccarelli F, Natalucci F, Picciariello L, Olivieri G, Cirillo A, Gelibter A, Picone V, Botticelli A, Conti F. Rheumatic Diseases Development in Patients Treated by Anti-PD1 Immune Checkpoint Inhibitors: A Single-Centre Descriptive Study. Life (Basel) 2023; 13:life13040877. [PMID: 37109406 PMCID: PMC10141051 DOI: 10.3390/life13040877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
The introduction of the so-called immune checkpoint inhibitors (ICIs) substantially changed the history of cancer therapy. On the other hand, they can induce the development of rheumatic immune-related adverse events (Rh-irAEs). In the scenario of a joint oncology/rheumatology outpatient clinic, we conducted a single-centre descriptive study to define from a laboratory, clinical and therapeutic point of view, rheumatic conditions developed during anti-PD1 treatment. The study included 32 patients (M/F 16/16, median age 69, IQR 16.5). According to the international classification criteria, eight patients could be classified as affected by Rheumatoid Arthritis, one by Psoriatic Arthritis, six by Polymyalgia Rheumatica, five by systemic connective tissue diseases (two systemic lupus erythematosus, two Sjögren’s syndrome, one undifferentiated connective tissue disease). The remaining patients were diagnosed as having undifferentiated arthritis or inflammatory arthralgia. The median interval between ICIs starting and the onset of symptoms was 14 weeks (IQR 19.75). Moving to treatment, the longitudinal observation revealed that all RA, PsA and CTD patients required the introduction of treatment with DMARDs. In conclusion, the growing use of ICIs in a real-life setting confirmed the possible development of different rheumatological conditions, further emphasising the need for shared oncology/rheumatology management.
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13
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Garbarino MC, Manzano N, Messina O, Zylberman M. Rheumatological adverse events secondary to immune checkpoint inhibitors. REUMATOLOGÍA CLÍNICA (ENGLISH EDITION) 2023; 19:215-222. [PMID: 37005129 DOI: 10.1016/j.reumae.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/29/2022] [Indexed: 04/03/2023]
Abstract
The first experiences with a group of drugs called immune checkpoint inhibitors for the treatment of cancer were described in 2010. They are currently used in many tumours, with successful survival outcomes but a new profile of adverse events. This new spectrum of immune-mediated toxicities includes an exaggerated inflammatory response of T lymphocyte and the development of autoimmune diseases or similar pathologies. Of these, of particular note are the rheumatological toxicities. This review aims to alert internists and rheumatologists to their recognition and clinical management.
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Affiliation(s)
- María Cecilia Garbarino
- Departamento de Medicina Interna, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina; Sección Reumatología, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina.
| | - Natalia Manzano
- Departamento de Medicina Interna, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Osvaldo Messina
- Sección Reumatología, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina
| | - Marcelo Zylberman
- Departamento de Medicina Interna, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina; Departamento de Medicina Interna, Instituto Alexander Fleming, Buenos Aires, Argentina
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14
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Grümme L, Schulze-Koops H. [Rheumatological side effects of checkpoint inhibitors and their treatment]. Z Rheumatol 2023; 82:187-194. [PMID: 36607420 DOI: 10.1007/s00393-022-01311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/07/2023]
Abstract
The spectrum of tumors for which checkpoint inhibitor (CI) treatment is used is constantly expanding. The European Medicines Agency has currently approved nine CIs: one anti-cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) CI, one anti-lymphocyte activation gene 3 (LAG-3) CI, four anti-programmed cell death protein 1 (PD-1) CIs and three anti-programmed death ligand 1 (PD-L1) CIs. By blocking immune checkpoints the physiological downregulation of T cell activity against autologous tissue is prevented. This results in an immunologically unregulated activation of T cells directed against malignant cells. Healthy tissue also expresses antigens and thereby continuously activates autologous T cells. Thus, the blockade of immune checkpoints can lead to T cell activity against healthy tissue (immune-related adverse events, irAE). The irAEs can occur in any organ system and approximately 10% of all patients under CI treatment develop rheumatological irAEs, mostly arthralgia and myalgia. The classification criteria of rheumatological diseases do not need to be met to initiate treatment and the primary goal of treatment of irAEs is to enable continuation of CI treatment. Rheumatological irAEs should be recognized and treated quickly. In the treatment of musculoskeletal irAEs, three stages can be defined. In the first stage, nonsteroidal anti-inflammatory drugs or intra-articular as well as systemic glucocorticoids are used. In the second stage, conventional synthetic and in the third stage, biologic disease-modifying antirheumatic drugs are used. The most severe musculoskeletal irAE is myositis with cardiac and/or respiratory involvement and/or myasthenia gravis. In addition to high-dose glucocorticoids, intravenous immunoglobulins or plasma exchange are used in treatment.
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Affiliation(s)
- Lea Grümme
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| | - Hendrik Schulze-Koops
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
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15
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De La Fuente F, Belkhir R, Henry J, Nguyen CD, Pham T, Germain V, Gavand PE, Labadie C, Briere C, Lauret A, Cardon T, Mouterde G, Bonnet I, Rouxel L, Truchetet ME, Schaeverbeke T, Richez C, Kostine M. Use of a bDMARD or tsDMARD for the management of inflammatory arthritis under checkpoint inhibitors: an observational study. RMD Open 2022; 8:rmdopen-2022-002612. [PMID: 36270747 PMCID: PMC9594531 DOI: 10.1136/rmdopen-2022-002612] [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: 07/26/2022] [Accepted: 10/02/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE There is limited experience regarding the use of biological disease-modifying antirheumatic drug (bDMARD) and JAK inhibitor (JAKi) for the management of immune checkpoint inhibitors (ICI)-induced inflammatory arthritis. We aimed to assess their efficacy and safety in this setting. METHODS Using the Club Rhumatismes and Inflammation French network, we conducted a multicentre, retrospective, observational study of patients with cancer diagnosed with inflammatory arthritis under ICI(s) and treated with bDMARD or JAKi. Clinical data were collected using a standardised case report form. RESULTS Twenty patients (60% men, median age 69.5 years) were included, with rheumatoid arthritis (RA)-like (n=16), polymyalgia rheumatica-like (n=2) or psoriatic arthritis-like (n=2) clinical presentation. Two patients had pre-existing RA. 90% were treated with glucocorticoids as first-line therapy and 60% received methotrexate prior to bDMARD or JAKi. Anti-interleukin-6 receptor (IL-6R) therapy was used in 13/20 patients (65%), leading to clinical improvement in 11/13 patients (85%), but one patient experienced intestinal perforation and cancer progression was noticed in 6/13 patients (46%). Tumour necrosis factor inhibitors were used in 5/20 patients (25%), with improvement in 4/5 patients (80%) and cancer progression was observed in 3/5 patients (60%). Two infections (diverticulitis and pneumonitis) were reported. Anakinra, baricitinib and ustekinumab were each used in one patient. Median duration of the bDMARD or JAKi was 17 weeks. CONCLUSION Anti-IL-6R therapy is currently the most common strategy in patients with ICI-induced inflammatory arthritis and insufficient response to glucocorticoids and methotrexate, leading to improvement in >80%. Overall, cancer progression occurred in about half of patients and whether the bDMARD/JAKi impacted the tumour response remains to be determined.
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Affiliation(s)
- Fanny De La Fuente
- Department of Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe Hospitalier Pellegrin, Bordeaux, France
| | - Rakiba Belkhir
- Department of Rheumatology, Hôpital Bicetre, Assistance Publique-Hôpitaux de Paris, FHU CARE, Le Kremlin-Bicetre, France,Inserm UMR 1184, Universite Paris-Saclay Faculte de Medecine, Le Kremlin-Bicetre, France
| | - Julien Henry
- Department of Rheumatology, Hôpital Bicetre, Assistance Publique-Hôpitaux de Paris, FHU CARE, Le Kremlin-Bicetre, France,Inserm UMR 1184, Universite Paris-Saclay Faculte de Medecine, Le Kremlin-Bicetre, France
| | - Chi Duc Nguyen
- Department of Rheumatology, Centre Hospitalier de Bethune, Bethune, France
| | - Thao Pham
- Department of Rheumatology, Sainte-Marguerite Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - Vincent Germain
- Department of Rheumatology, Centre Hospitalier de Pau, Pau, France
| | | | - Céline Labadie
- Department of Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe Hospitalier Pellegrin, Bordeaux, France
| | - Claire Briere
- Department of Internal Medicine, Centre Hospitalier Intercommunal de Creteil, Creteil, France
| | - Ambre Lauret
- Department of Internal Medicine, Centre Hospitalier Intercommunal de Creteil, Creteil, France
| | - Thierry Cardon
- Department of Rheumatology, Lille University Hospital Center, Lille, France
| | - Gael Mouterde
- Departement of Rheumatology, Lapeyronie Hospital, Montpellier, France
| | - Isabelle Bonnet
- Department of Rheumatology, Hôpital Bicetre, Assistance Publique-Hôpitaux de Paris, FHU CARE, Le Kremlin-Bicetre, France,Inserm UMR 1184, Universite Paris-Saclay Faculte de Medecine, Le Kremlin-Bicetre, France
| | - Léa Rouxel
- Department of Rheumatology, Arcachon Hospital, La Teste de Buch, France
| | - Marie-Elise Truchetet
- Department of Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe Hospitalier Pellegrin, Bordeaux, France
| | - Thierry Schaeverbeke
- Department of Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe Hospitalier Pellegrin, Bordeaux, France
| | - Christophe Richez
- Department of Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe Hospitalier Pellegrin, Bordeaux, France
| | - Marie Kostine
- Department of Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe Hospitalier Pellegrin, Bordeaux, France
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16
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Bruera S, Suarez-Almazor ME. The effects of glucocorticoids and immunosuppressants on cancer outcomes in checkpoint inhibitor therapy. Front Oncol 2022; 12:928390. [PMID: 36081549 PMCID: PMC9445222 DOI: 10.3389/fonc.2022.928390] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
The emergence of checkpoint inhibitors has created a paradigm shift for the treatment of various malignancies. However, although these therapies are associated with improved survival rates, they also carry the risk of immune-related adverse events (irAEs). Moderate to severe irAEs are typically treated with glucocorticoids, sometimes with the addition of immunosuppressants as steroid-sparing therapy. However, it is unclear how glucocorticoids and immunosuppressants may impact cancer survival and the efficacy of immune checkpoint therapy on cancer. In this narrative review, we discuss the effects of glucocorticoids and immunosuppressants including methotrexate, hydroxychloroquine, azathioprine, mycophenolate mofetil, tumor-necrosis factor (TNF)-inhibitors, interleukin-6 inhibitors, interleukin-1 inhibitors, abatacept, rituximab, and Janus kinase inhibitors (JAKi) on cancer-specific outcomes in the setting of immune checkpoint inhibitor use.
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Affiliation(s)
- Sebastian Bruera
- Section of Immunology, Allergy and Rheumatology, Baylor College of Medicine, Houston, TX, United States
| | - Maria E. Suarez-Almazor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- *Correspondence: Maria E. Suarez-Almazor,
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17
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Imaging Findings in Patients with Immune Checkpoint Inhibitor-Induced Arthritis. Diagnostics (Basel) 2022; 12:diagnostics12081961. [PMID: 36010310 PMCID: PMC9406920 DOI: 10.3390/diagnostics12081961] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 01/27/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)-induced arthritis is an increasingly recognized adverse event in patients with oncologic disease during immunotherapy. Four patterns are well described, including rheumatoid arthritis (RA)-like, polymyalgia rheumatica (PMR)-like, psoriatic arthritis (PsA)-like, and oligo-monoarthritis, among others. Despite better clinical recognition of these syndromes, information about the main imaging findings is limited. Methods: We conducted a retrospective observational study including all adult patients referred to the Rheumatology Department of a single-center due to ICI-induced arthritis who underwent imaging studies [ultrasound (US), magnetic resonance imaging (MRI), and 18F-FDG PET/CT)] between January 2017 and January 2022. Results: Nineteen patients with ICI-induced arthritis with at least one diagnostic imaging assessment were identified (15 US, 4 MRI, 2 18F-FDG PET/CT). Most patients were male (84.2%), with a median age at inclusion of 73 years. The main underlying diagnoses for ICI treatment were melanoma in five cases. The distribution of ICI-induced arthritis was as follows: PMR-like (5, 26.2%), RA-like (4, 21.1%), PsA-like (4, 21.1%), and others (6, 31.6%). All RA-like patients had US findings indistinguishable from conventional RA patients. In addition, 3/5 (60%) of PMR-like patients had significant involvement of the hands and wrists. Abnormal findings on MRI or PET-CT were reported by clinical symptoms. No erosions or myofascitis were seen. Conclusions: ICI-induced arthritis patients present inflammatory patterns on imaging studies similar to conventional inflammatory arthropathies, and therefore these syndromes should be followed carefully and treated according to these findings.
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18
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Chan KK, Bass AR. Monitoring and Management of the Patient with Immune Checkpoint Inhibitor-Induced Inflammatory Arthritis: Current Perspectives. J Inflamm Res 2022; 15:3105-3118. [PMID: 35642215 PMCID: PMC9148583 DOI: 10.2147/jir.s282600] [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: 01/20/2022] [Accepted: 03/18/2022] [Indexed: 11/23/2022] Open
Abstract
In this review, we draw from observational studies, treatment guidelines and our own clinical experience to describe approaches to monitoring and management of immune checkpoint inhibitor (ICI)-induced inflammatory arthritis, including polymyalgia rheumatica. This condition occurs in about 4% of ICI-treated cancer patients and can persist for a year or longer. Mild arthritis can generally be managed with non-steroidal anti-inflammatory drugs, intraarticular steroids injections and/or low dose corticosteroids. Higher grade arthritis should be brought under control with corticosteroids, but early introduction of a steroid-sparing agent is recommended to minimize steroid toxicity. In order to assess the effectiveness of any arthritis treatment, tender and swollen joint counts and patient reported measures of physical function, such as the health assessment questionnaire, should be obtained at each visit. Referral to a rheumatologist is recommended for patients with high grade arthritis to help guide the use of disease-modifying antirheumatic drugs.
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Affiliation(s)
- Karmela K Chan
- Department of Medicine, Hospital for Special Surgery/Weill Cornell Medicine, New York, NY, USA
| | - Anne R Bass
- Department of Medicine, Hospital for Special Surgery/Weill Cornell Medicine, New York, NY, USA
- Correspondence: Anne R Bass, Email
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19
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Distinct molecular and immune hallmarks of inflammatory arthritis induced by immune checkpoint inhibitors for cancer therapy. Nat Commun 2022; 13:1970. [PMID: 35413951 PMCID: PMC9005525 DOI: 10.1038/s41467-022-29539-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 03/17/2022] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors are associated with immune-related adverse events (irAEs), including arthritis (arthritis-irAE). Management of arthritis-irAE is challenging because immunomodulatory therapy for arthritis should not impede antitumor immunity. Understanding of the mechanisms of arthritis-irAE is critical to overcome this challenge, but the pathophysiology remains unknown. Here, we comprehensively analyze peripheral blood and/or synovial fluid samples from 20 patients with arthritis-irAE, and unmask a prominent Th1-CD8+ T cell axis in both blood and inflamed joints. CX3CR1hi CD8+ T cells in blood and CXCR3hi CD8+ T cells in synovial fluid, the most clonally expanded T cells, significantly share TCR repertoires. The migration of blood CX3CR1hi CD8+ T cells into joints is possibly mediated by CXCL9/10/11/16 expressed by myeloid cells. Furthermore, arthritis after combined CTLA-4 and PD-1 inhibitor therapy preferentially has enhanced Th17 and transient Th1/Th17 cell signatures. Our data provide insights into the mechanisms, predictive biomarkers, and therapeutic targets for arthritis-irAE. Arthritis is the most common rheumatic immune-related adverse event (irAE) occurring in cancer patients receiving immune checkpoint inhibitors. Here the authors study the immune landscape of blood and synovial fluid samples from patients with arthritis-irAE, reporting immunological differences and similarities with classic autoimmune arthritis.
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Abstract
Immune checkpoint inhibitors activate the immune system to combat cancer. In doing so, however, they can cause immune-related adverse events (irAEs), including rheumatic syndromes, such as inflammatory arthritis, polymyalgia rheumatica, and myositis. This article reviews rheumatic irAEs that may be encountered in the general medicine practice and provides guidance to support prompt recognition, referral, and treatment of these patients.
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Affiliation(s)
- Nilasha Ghosh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Anne R Bass
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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21
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Jensen AK, Chatzidionysiou K, Torp CK, Sørensen AS, Tenstad HB, Schäfer VS, Kostine M, Jacobsen S, Leipe J, Kragstrup TW. Comparison of immune checkpoint inhibitor-induced arthritis and reactive arthritis to inform therapeutic strategy. Biomed Pharmacother 2022; 148:112687. [PMID: 35228067 DOI: 10.1016/j.biopha.2022.112687] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA) is a relatively new disease entity caused by ICI agents during cancer therapy. Reactive arthritis (ReA) is a well-known disease entity caused by urogenital or gastrointestinal bacterial infection or pneumonia. In this sense, ICI-IA and ReA are both defined by a reaction to a well-specified causal event. As a result, comparing these diseases may help to determine therapeutic strategies. METHODS We compared ICI-IA and ReA with special focus on pharmacological management. Specifically regarding treatment, we conducted a literature search of studies published in the PubMed database. Inclusion criteria were studies on treatment with non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GC), or disease modifying antirheumatic drugs (DMARDs) in ICI-IA or ReA. During systematic selection, 21 studies evaluating ICI-IA and 14 studies evaluating ReA were included. RESULTS In ICI-IA, prospective and retrospective studies have shown effects of non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoid (GC), sulfasalazine (SSZ), methotrexate (MTX), hydroxychloroquine (HCQ) and TNFi. In ReA, retrospective studies evaluated NSAIDs and GC. A randomized controlled trial reported the effect of SSZ, and a retrospective study reported the effect of MTX and SSZ in combination with tumor necrosis factor alpha inhibition (TNFi). For both entities, small case reports show treatment effects of interleukin 6 receptor inhibition (IL-6Ri). DISCUSSION This literature review identified both similarities and differences regarding the pathogenesis and clinical features of ReA and ICI-IA. Studies on treatment reported effectiveness of NSAIDs, GC, MTX, SSZ and TNFi in both diseases. Further, small case reports showed effects of IL-6Ri.
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Affiliation(s)
- Anders Kirkegaard Jensen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Sygehus Lillebælt, Kolding, Denmark
| | - Katerina Chatzidionysiou
- Department of Medicine Solna, Karolinska Institutet, Rheumatology Unit, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Valentin S Schäfer
- Clinic of Internal Medicine III, Department of Oncology, Hematology, Rheumatology and Clinical Immunology, University Hospital Bonn, Bonn, Germany
| | - Marie Kostine
- Department of Rheumatology, Bordeaux, University, Hospital, France
| | - Søren Jacobsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
| | - Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Germany.
| | - Tue Wenzel Kragstrup
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.
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Cho Y, Anderson EW, Guevara SJ, Miyara SJ, Maria N, Metz CN, Zafeiropoulos S, Giannis D, Wang J, Abidoye O, Mumford JM, Aronsohn J, Molmenti E, Sohail H. Diagnostic Dilemma of Paraneoplastic Rheumatic Disorders: Case Series and Narrative Review. Cureus 2021; 13:e19993. [PMID: 34984145 PMCID: PMC8715838 DOI: 10.7759/cureus.19993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/27/2022] Open
Abstract
Paraneoplastic rheumatic disorder (RD) is a disorder that may present before, concurrent with, or after the diagnosis of malignancy. Paraneoplastic RDs are a clinical expression of occult cancer that is not directly related to a tumor or metastasis and manifests as rheumatoid symptoms. The RD is determined by the organ system affected by articular, muscular, cutaneous, vascular, or miscellaneous symptoms. Each case is challenging to diagnose because cancer may present with similar symptoms as a common rheumatic disorder. Of note, the majority of cases have minimal responsiveness or no responsiveness to standard rheumatoid treatment. Therefore, it is imperative to recognize and treat the underlying cancer accordingly. Herein, we present four different diagnostic dilemma cases of RD: case #1 - leukocytoclastic vasculitis and C3 glomerulopathy, case #2 - scleroderma, case #3 - Raynaud’s syndrome and possible lupus-like syndrome, and case #4 - inflammatory myositis. Institutional IRB approval was obtained for this case series. We will discuss and review the literature on each topic. In addition, we will mention a review of paraneoplastic rheumatoid arthritis. As rheumatic disease is associated with the use of immune checkpoint inhibitors (ICIs) for cancer treatment, we will briefly discuss some of the most common rheumatic presentations in the setting of these drugs. This case review aims to inform clinicians about the atypical presentation of paraneoplastic RD and to highlight the need for interdisciplinary management between rheumatologists, oncologists, and primary care practitioners.
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23
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Shen P, Deng X, Hu Z, Chen Z, Huang Y, Wang K, Qin K, Huang Y, Ba X, Yan J, Han L, Tu S. Rheumatic Manifestations and Diseases From Immune Checkpoint Inhibitors in Cancer Immunotherapy. Front Med (Lausanne) 2021; 8:762247. [PMID: 34805229 PMCID: PMC8599930 DOI: 10.3389/fmed.2021.762247] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/13/2021] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs), which can enhance antitumor immunity and inhibit cancer growth, have revolutionized the treatment of multiple cancers and dramatically decreased mortality. However, treatment with ICIs is directly associated with immune-related adverse events (irAEs) because of inflammation in off-target organs and autoimmunity resulting from non-specific immune activation. These irAEs can cause rheumatic diseases and manifestations such as inflammatory arthritis, polymyalgia rheumatica, myositis, vasculitis, Sicca and Sjogen's syndrome, and systemic lupus erythematosus. Early diagnosis and treatment of these adverse events will improve outcomes and quality of life for cancer patients. The treatment of rheumatic diseases induced by ICIs requires multidisciplinary cooperation among physicians. Furthermore, the underlying mechanisms are not fully understood and it is difficult to predict and evaluate these side effects precisely. In this review, we summarize available studies and findings about rheumatic irAEs, focusing mainly on the clinical manifestations, epidemiology, possible mechanisms, and guiding principles for treating these irAEs.
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Affiliation(s)
- Pan Shen
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xuan Deng
- Department of Nephrology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhishuo Hu
- Department of Emergency, Wuhan No.1 Hospital, Wuhan, China
| | - Zhe Chen
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yao Huang
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ke Wang
- Department of Integrated Traditional Chinese and Western Medicine, The Central Hospital of Wuhan, Wuhan, China
| | - Kai Qin
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ying Huang
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xin Ba
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jiahui Yan
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Liang Han
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Shenghao Tu
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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24
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Dietz H, Weinmann SC, Salama AK. Checkpoint Inhibitors in Melanoma Patients with Underlying Autoimmune Disease. Cancer Manag Res 2021; 13:8199-8208. [PMID: 34754240 PMCID: PMC8572012 DOI: 10.2147/cmar.s283217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/25/2021] [Indexed: 12/18/2022] Open
Abstract
The development of immune checkpoint inhibitors (ICI) has dramatically changed the clinical management of metastatic melanoma and other solid tumors. Despite exclusion from initial clinical trials, there is a growing body of retrospective data that suggest ICI can be used in patients with underlying autoimmune disease (AID) with a tolerable level of anticipated immune-related adverse events (irAEs) and a rate of severe irAEs comparable to that of patients without underlying AID. Coordination with other subspecialists and careful monitoring for irAEs is critical in safely managing these patients. Studies exploring novel approaches examining the use of targeted immunosuppressants in the prevention and management of irAEs, as well as multiple studies currently underway are aimed at establishing safe clinical practices when using ICI in patients with underlying AID.
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Affiliation(s)
- Hilary Dietz
- Division of Medical Oncology, Duke University, Durham, NC, USA
| | - Sophia C Weinmann
- Division of Rheumatology and Immunology, Duke University, Durham, NC, USA
| | - April K Salama
- Division of Medical Oncology, Duke University, Durham, NC, USA
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25
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Lindsay SE, Wurster L, Woolf K, Gundle KR. An Unusual Presentation of Inflammatory Shoulder Arthritis Associated with Nivolumab: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00022. [PMID: 34669677 DOI: 10.2106/jbjs.cc.21.00301] [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: 06/13/2023]
Abstract
CASE A 68-year-old woman with a history of stage IIIC (T3bN1bM0) melanoma with metastases to her right axilla status after 10 cycles of nivolumab presented with right shoulder pain. Radiographs showed a progressive erosive glenohumeral joint lesion. The workup was negative for metastasis and infection. Her clinical and radiographic findings were consistent with erosive arthritis. The patient underwent shoulder hemiarthroplasty and experienced substantial improvements. CONCLUSION This is an unusual case of inflammatory arthritis associated with nivolumab, an antiprogrammed cell death protein 1, and is an important reminder of the musculoskeletal toxicities associated with immunotherapies.
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Affiliation(s)
- Sarah E Lindsay
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - Lindsey Wurster
- Operative Care Division, Portland VA Medical Center, Portland, Oregon
| | - Kirsten Woolf
- Department of Pathology, Portland VA Medical Center, Portland, Oregon
| | - Kenneth R Gundle
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
- Operative Care Division, Portland VA Medical Center, Portland, Oregon
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26
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Cano-Cruz LG, Barrera-Vargas A, Mateos-Soria A, Soto-Perez-de-Celis E, Merayo-Chalico J. Rheumatological Immune-related Adverse Events of Checkpoints Inhibitors: a Narrative Review for the Latin American Rheumatologist. Arch Med Res 2021; 53:113-121. [PMID: 34649738 DOI: 10.1016/j.arcmed.2021.09.004] [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: 02/11/2021] [Accepted: 09/23/2021] [Indexed: 11/02/2022]
Abstract
Latin America is experiencing a demographic and epidemiological transition, with an increase in non-communicable diseases such as cancer. One of the greatest advances in the therapeutic approach to cancer has been the discovery of immunotherapy, and specifically of checkpoint inhibitors (CPIs). Since inhibition of CTLA-4 and PD-1/PD-L1 enhances the immune response, cancer immunotherapies are associated with a new class of toxicities of autoimmune and/or autoinflammatory origin. These immune-related adverse events (irAEs) result in a broad spectrum of clinical events including rheumatic clinical syndromes, which may resemble classic rheumatic diseases. The most common rheumatic manifestations include inflammatory arthritis, myositis, vasculitis, and sicca syndrome. Recognizing rheumatologic irAEs is challenging due to the wide spectrum of clinical presentations that often do not fulfill traditional classification criteria of rheumatic diseases. A delayed diagnosis and treatment can lead to long-term disability, and disorders may become chronic and require ongoing immunosuppressive therapy. The management of irAEs includes the prompt detection and appropriate grading since their management is dictated by their severity. The growing use of CPIs, and the ensuing increase in irAEs, warrants an increasing collaboration between rheumatologists and oncologists. Understanding the pathophysiology, diagnosis, grading, and therapeutic implications of irAEs in patients with cancer is thus a requirement for Latin American oncologists and rheumatologists alike.
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Affiliation(s)
- Lilian Guadalupe Cano-Cruz
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Ana Barrera-Vargas
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Abigail Mateos-Soria
- Departamento de Hemato-Oncología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Enrique Soto-Perez-de-Celis
- Departamento de Geriatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Javier Merayo-Chalico
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
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27
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Manzo C. Rheumatic Immuno-related Adverse Events following Immunotherapy with Checkpoint Inhibitors: Adverse Drug Reaction, or Other? Mediterr J Rheumatol 2021; 32:186-187. [PMID: 34447920 PMCID: PMC8369280 DOI: 10.31138/mjr.32.2.186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/17/2021] [Accepted: 02/03/2021] [Indexed: 12/26/2022] Open
Affiliation(s)
- Ciro Manzo
- Azienda Sanitaria Locale Napoli 3 sud, Internal and Geriatric Medicine Department - Geronthorheumatological Outpatient Clinic, Poliambulatorio "Mariano Lauro", Sant'Agnello, Naples, Italy
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28
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Harris JA, Huang K, Miloslavsky E, Hanna GJ. Sicca syndrome associated with immune checkpoint inhibitor therapy. Oral Dis 2021; 28:2083-2092. [PMID: 34379884 DOI: 10.1111/odi.14000] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/07/2021] [Accepted: 08/03/2021] [Indexed: 12/17/2022]
Abstract
Cancer immunotherapy, which seeks to stimulate a patient's own immune system to combat cancer, is quickly becoming a central pillar of cancer therapeutics and has resulted in the development of many novel anticancer therapies. One subtype of cancer immunotherapy, immune checkpoint inhibitors (ICIs), has revolutionized cancer treatment and changed the standard of care for multiple indications. However, the advent of ICIs has produced a wide variety of inflammatory side effects termed immune-related adverse events (IRAEs), including ICI-induced Sicca syndrome. This article outlines the clinical features of ICI-induced Sicca syndrome and assesses its reported incidence in clinical trials, case series, and case reports across numerous cancers and treatment modalities. Presentations of ICI-induced Sicca syndrome in patients with pre-existing Sjӧgren's disease and with extra-glandular manifestations will also be explored. The pathophysiological mechanisms underlying IRAEs, including ICI-induced Sicca syndrome, will be evaluated through an examination of existing literature. Finally, the various treatment and management strategies as well as aims for future work will be discussed and reviewed.
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Affiliation(s)
- Jack A Harris
- Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Kevin Huang
- Harvard Medical School, Boston, Massachusetts, USA
| | - Eli Miloslavsky
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Glenn J Hanna
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Tingry T, Massy E, Piperno M, Auroux M, Kostine M, Maillet D, Amini-Adle M, Fabien N, Estublier C, Goncalves D, Girard N, Confavreux CB. [Rheumatic immune adverse events related to immune checkpoint inhibitors-(IrAEs related to ICI)]. Bull Cancer 2021; 108:643-653. [PMID: 33902919 DOI: 10.1016/j.bulcan.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 12/17/2022]
Abstract
New anti-cancer therapeutics have been developed in the recent years and dramatically change prognosis and patient management. Either used alone or in combination, immune checkpoint inhibitors (ICI), such as anti-CTLA-4 and anti-PD1/PD-(L)1, act by removing T-cell inhibition to enhance their antitumor response. This change in therapeutic targets leads to a break in immune-tolerance and a unique toxicity profile resulting in immune complications. These side effects, called Immune-Related Adverse Events (IrAEs), can affect all organs, with a wide range of clinical and biological presentations and severity. Various rheumatic and musculoskeletal manifestations have been reported in the literature, ranging from mild arthralgia, polymyalgia rheumatica, to genuine serodefined rheumatoid arthritis and myositis. Tolerance studies suggest some correlations between IrAEs occurrence and tumor response. Assessment of patient musculoskeletal status prior to the start of the ICI is warranted. Management of rheumatic IrAEs does not usually request ICI discontinuation, exception for myositis or very severe forms where it should be discussed. Treatment relies on non-steroidal anti-inflammatory drugs (NSAIDs) or low dose glucocortioids (<20mg per day). Dose should be adjusted according to severity. The use of disease modifying anti-rheumatic drugs (DMARDs), either conventional and/or biological should be very cautious and result from a shared decision between oncologist and rheumatologist to best manage dysimmunitary complications without hampering the antitumor efficacy of ICI.
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Affiliation(s)
- Thomas Tingry
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Emmanuel Massy
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Muriel Piperno
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Maxime Auroux
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France
| | - Marie Kostine
- Centre hospitalier universitaire de Bordeaux, département de rhumatologie, 33000 Bordeaux, France
| | - Denis Maillet
- Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France; Centre Hospitalier Lyon Sud, Hospices civils de Lyon, service d'oncologie médicale, 69310 Pierre Bénite, France
| | - Mona Amini-Adle
- Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France; Centre de lutte contre le cancer Léon-Bérard, service de dermatologie, 69003 Lyon, France
| | - Nicole Fabien
- Centre Hospitalier Lyon Sud, hospices civils de Lyon, laboratoire d'auto-immunité, 69310 Pierre Bénite, France
| | - Charline Estublier
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - David Goncalves
- Centre Hospitalier Lyon Sud, hospices civils de Lyon, laboratoire d'auto-immunité, 69310 Pierre Bénite, France
| | - Nicolas Girard
- Institut Curie, institut du Thorax Curie Montsouris, 75005 Paris, France
| | - Cyrille B Confavreux
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France.
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Abstract
Immune checkpoint inhibitors activate the immune system to combat cancer. In doing so, however, they can cause immune-related adverse events (irAEs), including rheumatic syndromes, such as inflammatory arthritis, polymyalgia rheumatica, and myositis. This article reviews rheumatic irAEs that may be encountered in the general medicine practice and provides guidance to support prompt recognition, referral, and treatment of these patients.
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Affiliation(s)
- Nilasha Ghosh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Anne R Bass
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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31
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Abstract
PURPOSE OF REVIEW This review summarizes the current evidence on treatment strategies for inflammatory arthritis because of cancer treatment with immune checkpoint inhibitors (ICI), prognosis of ICI-induced arthritis, and management of patients with preexisting inflammatory arthritis receiving ICI therapy. RECENT FINDINGS Inflammatory arthritis is the most common rheumatic immune-related adverse event observed in patients receiving ICI therapy. Most patients can successfully be treated with low doses of corticosteroids or conventional synthetic disease modifying anti-rheumatic drugs (DMARDs). A small minority will develop severe symptoms requiring biologic therapy including TNF inhibitors and IL-6 receptor inhibitors. Many cases of inflammatory arthritis will resolve with cessation of ICI therapy. Some patients will develop persistent arthritis despite discontinuation. Patients with preexisting inflammatory arthritis (e.g. rheumatoid arthritis) commonly flare on ICI therapy, but can usually be managed with corticosteroids. SUMMARY Inflammatory arthritis following ICI therapy for cancer is relatively common and the practicing rheumatologist should be able to recognize and manage it in conjunction with Oncology. The majority of patients respond to corticosteroids, but some will need treatment with conventional synthetic or biologic DMARDs. Additional studies should investigate the effects of immunosuppression on tumor response and the use of ICI therapy in patients with preexisting autoimmune disease.
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32
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Pagkopoulou E, Simopoulou T, Maragkouli E, Perifanou-Sotiri S, Kotsakis A, Bogdanos DP. Arthritis and Myositis in a Patient Treated with Programmed Cell Death-1 (PD-1) Inhibitor Pembrolizumab for Lung Cancer. Mediterr J Rheumatol 2020; 31:355-357. [PMID: 33163870 PMCID: PMC7641028 DOI: 10.31138/mjr.31.3.355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/17/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a new class of drug that have demonstrated efficacy across many cancer types. Because of their nature and mode of action, ICIs unleash immune activation raising concerns as to whether they can be used in patients with concomitant autoimmune or auto-inflammatory diseases. Their usage can lead to the development of autoimmune phenomena known as immune related adverse events (irAEs), virtually affecting every organ. As the use of ICIs is drastically increasing, evidence of irAEs has been accumulating. Herein, we report a case of inflammatory myositis and arthritis 6 months after pembrolizumab therapy, an anti-programmed death-1 (PD1) ICI in a patient with lung cancer, aiming at raising awareness of the diagnostic and clinical challenges clinicians may face when checkpoint inhibitors-related rheumatologic irAEs are developed.
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Affiliation(s)
| | | | - Eleni Maragkouli
- Department of Oncology, University General Hospital of Larissa, School of Health Sciences University of Thessaly, Larissa, Greece
| | | | - Athanasios Kotsakis
- Department of Oncology, University General Hospital of Larissa, School of Health Sciences University of Thessaly, Larissa, Greece
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Durrechou Q, Domblides C, Sionneau B, Lefort F, Quivy A, Ravaud A, Gross-Goupil M, Daste A. Management of Immune Checkpoint Inhibitor Toxicities. Cancer Manag Res 2020; 12:9139-9158. [PMID: 33061607 PMCID: PMC7533913 DOI: 10.2147/cmar.s218756] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/07/2020] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have radically changed the clinical outcome of several cancers with durable responses. CTLA-4 (cytotoxic T lymphocyte antigen-4), PD-1 (programmed cell death protein 1) or PDL-1 (programmed cell death ligand protein 1) represent ICIs that can be used as monotherapy or in combination with other agents. The toxicity p\rofiles of ICIs differ from the side effects of cytotoxic agents and come with new toxicities like immune-related adverse events. Typically, these toxicities occur in all organs. However, the main organs affected are the skin, digestive, hepatic, lungs, rheumatologic, and endocrine. Most of the immune toxicity that occurs is low grade but some more severe toxicities can occur that require a rapid diagnosis and appropriate treatment. The recognition of symptoms by physicians and patient is necessary to resolve them rapidly and adapt treatment to allow the toxicity to resolve.
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Affiliation(s)
- Quentin Durrechou
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Charlotte Domblides
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France.,ImmunoConcEpt, CNRS UMR 5164, Bordeaux University, Bordeaux 33076, France
| | - Baptiste Sionneau
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Felix Lefort
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Amandine Quivy
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Alain Ravaud
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Marine Gross-Goupil
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
| | - Amaury Daste
- Department of Medical Oncology, Hôpital Saint-André, CHU Bordeaux-University of Bordeaux, Bordeaux, France
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34
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Benesova K, Leipe J. Nebenwirkungen immunonkologischer Therapien. AKTUEL RHEUMATOL 2020. [DOI: 10.1055/a-1209-0659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungImmunonkologische Therapien und insbesondere die Immuncheckpoint-Inhibitoren (ICPi) als Hauptvertreter dieser neuen Substanzklasse kommen bei zunehmender Anzahl von soliden und teils auch hämatologischen Tumorentitäten und Indikationen zum Einsatz. Die relativ hohen (Langzeit-)Tumoransprechraten auch in fortgeschrittenen und therapierefraktären Stadien haben die therapeutischen Möglichkeiten der Onkologie geradezu revolutioniert. Gleichzeitig bringt der zunehmende Einsatz von ICPi auch neue Herausforderungen: Immunonkologische Therapien verursachen ein breites Spektrum an autoimmunen Nebenwirkungen, sogenannten „immune-related adverse events“ (irAEs), die teilweise klassischen Autoimmunopathien ähneln und jedes Organsystem betreffen können. Die große Mehrheit der ICPi-behandelten Patienten erlebt ein irAE an mindestens einem Organsystem und davon weisen ca. 5–20% ein rheumatisches irAEs auf. Diese sind interessanterweise mit einem besseren Tumoransprechraten bei ICPi-Therapie assoziiert und können entweder die Erstmanifestation einer klassischen entzündlich-rheumatischen Erkrankung oder auch nur eine transiente Nebenwirkung mit spezifischen Charakteristika sein. Zweifelsohne wird das interdisziplinäre Management immunvermittelter Nebenwirkungen auch den Rheumatologen in den nächsten Jahren zunehmend beschäftigen. Der vorliegende Artikel fasst die Erkenntnisse zum klinischen Management von irAEs für den praktizierenden Rheumatologen zusammen.
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Affiliation(s)
- Karolina Benesova
- Sektion Rheumatologie, Abteilung Innere Medizin V Hämatologie Onkologie Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg
| | - Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München Medizinische Fakultät, München
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35
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Silent acute appendicitis revealed by PET-CT during treatment with ipilimumab and nivolumab: a new immune-related adverse event. Cancer Immunol Immunother 2020; 69:2409-2410. [PMID: 32964272 DOI: 10.1007/s00262-020-02724-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022]
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Williams SG, Mollaeian A, Katz JD, Gupta S. Immune checkpoint inhibitor-induced inflammatory arthritis: identification and management. Expert Rev Clin Immunol 2020; 16:771-785. [PMID: 32772596 DOI: 10.1080/1744666x.2020.1804362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have proved to be groundbreaking in the field of oncology. However, immune system overactivation from ICIs has introduced a novel medical entity known as immune-related adverse events (irAEs), that can affect any organ or tissue. ICI-induced inflammatory arthritis (ICI-IIA) is the most common musculoskeletal irAE and can lead to significant morbidity and limitation in anti-cancer therapy. AREAS COVERED In this review, the authors focus on ICI-IIA. Relevant articles were identified through PubMed searches, spanning 2010 to the present. The authors detail the current understanding of its pathogenesis, diagnostic evaluation, and management strategies. EXPERT OPINION ICI-IIA is a complex irAE that we are just beginning to understand mechanistically and pathologically. It often presents later in the disease course than other irAEs and, due to various reasons, is under-recognized. In some patients, ICI-IIA may become a chronic disease, which distinguishes it from most irAEs that resolve after ICI discontinuation. Multiple important questions still demand further research including which patients may develop ICI-IIA? What are possible diagnostic and prognostic markers? Do anti-arthritis therapies interfere with the anti-tumor response? and when should steroid-sparing agents be initiated? Close collaboration and shared decision-making between oncologists, rheumatologists, and the patient are essential when managing this particular irAE.
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Affiliation(s)
- Sandra G Williams
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
| | - Arash Mollaeian
- Department of Medicine, MedStar Health Internal Medicine Residency Program , Baltimore, MD, USA
| | - James D Katz
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
| | - Sarthak Gupta
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
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Immune checkpoint inhibitor-induced musculoskeletal manifestations. Rheumatol Int 2020; 41:33-42. [PMID: 32743706 DOI: 10.1007/s00296-020-04665-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibitors (ICI) associate with a wide range of immune-related adverse events (Ir-AE), including musculoskeletal manifestations. We aimed at identifying all studies reporting musculoskeletal Ir-AE. An electronic (Medline, Scopus and Web of Science) search was performed using two sets of key words. The first set consisted of: arthritis, musculoskeletal, polymyalgia rheumatica and myositis. The second set consisted of: anti-PD-1, anti-PD-L1, anti-CTLA-4, ipilimumab, tremelimumab, pembrolizumab, nivolumab, atezolizumab, avelumab and durvalumab. We identified 3 prospective studies, 17 retrospective studies and 4 case series reporting 363 patients in total. Combined data from all three prospective studies provide a prevalence rate of 6.13%. Most patients were males (59.68%) and the vast majority (73%) were on programmed death-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors. Most studies report a median time of ≤ 12 weeks from first ICI administration to symptom onset. The main clinical phenotypes reported were: (a) inflammatory arthritis (57.57%), (b) myositis (14.04%) and (c) polymyalgia rheumatica (PMR) (12.12%). A total of 256 patients required steroids (70.52%) and 67 patients (18.45%) were treated with DMARDs. Positive auto-antibodies and family history of any autoimmune disease were present in 18.48% and 19.04% of cases, respectively. Only a few patients (19%) had to discontinue treatment due to musculoskeletal Ir-AE. Two prospective studies show that significantly more patients with musculoskeletal Ir-AE exhibit a favorable oncologic response compared to patients not exhibiting such manifestations whereas retrospective studies show that 77.22% of patients with musculoskeletal Ir-AE have a good tumor response. One out of 15 patients treated with ICI will develop musculoskeletal Ir-AE; in most cases the severity of these manifestations is mild/moderate and usually ICI may be continued. Rheumatologists should familiarize with this new clinical entity and develop relevant therapeutic algorithms.
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Roberts J, Ennis D, Hudson M, Ye C, Saltman A, Himmel M, Rottapel R, Pope J, Hoa S, Tisseverasinghe A, Fifi-Mah A, Maltez N, Jamal S. Rheumatic immune-related adverse events associated with cancer immunotherapy: A nationwide multi-center cohort. Autoimmun Rev 2020; 19:102595. [DOI: 10.1016/j.autrev.2020.102595] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022]
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Zhong H, Zhou J, Xu D, Zeng X. Rheumatic immune-related adverse events induced by immune checkpoint inhibitors. Asia Pac J Clin Oncol 2020; 17:178-185. [PMID: 32717098 PMCID: PMC8246553 DOI: 10.1111/ajco.13346] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/26/2020] [Indexed: 12/11/2022]
Abstract
Immune checkpoint inhibitors (ICIs) block the major inhibitory pathways in T cells, resulting in an augmented antitumor response. Immune‐related adverse events (irAEs) are a new class of side effects caused by ICIs and tend to be more prevalent in patients with preexisting autoantibodies and autoimmune diseases. The rheumatic subset of irAEs mainly includes arthralgia, arthritis, myalgia, myositis, vasculitis, sicca syndrome, scleroderma and systemic lupus erythematosus. The most common classification system for AEs, the Common Terminology Criteria for Adverse Events, is of limited use for irAEs, especially rheumatic irAEs. Therapy with glucocorticoid and temporary or permanent discontinuation of ICIs are the cornerstones of irAE treatment, and can be complemented with immunosuppressants (e.g., methotrexate), biologic agents (e.g., tumor necrosis factor inhibitors and interleukin‐6 receptor antagonists), intravenous immunoglobin and plasma exchange. Thus, the evaluation and treatment of rheumatic irAEs require multidisciplinary cooperation among physicians. Here, we review the most prevalent ICI‐associated rheumatic irAEs.
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Affiliation(s)
- Hui Zhong
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Jiaxin Zhou
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
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Immune Checkpoint Inhibition-Does It Cause Rheumatic Diseases? Mechanisms of Cancer-Associated Loss of Tolerance and Pathogenesis of Autoimmunity. Rheum Dis Clin North Am 2020; 46:587-603. [PMID: 32631606 DOI: 10.1016/j.rdc.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mechanisms of immune checkpoints and their role in autoimmunity are discussed in the context of immune checkpoint inhibitor (ICI) therapy for cancer. The updated clinical spectrum of immune-related adverse events (irAEs), with an in-depth discussion of rheumatic irAEs, is presented. The relationship between ICI-induced loss of self-tolerance in cancer and the implications for understanding of irAEs, rheumatic irAEs in particular, is overviewed.
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41
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[Clinical management of rheumatic immune-related adverse events : Recognize and treat rheumatological side effects of checkpoint inhibition]. Z Rheumatol 2020; 79:545-553. [PMID: 32613268 DOI: 10.1007/s00393-020-00825-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Immune checkpoint inhibitors (ICPi) represent a major breakthrough in the treatment and prognosis of many cancers, particularly of malignant melanoma and non-small cell lung cancer; however, the high tumor response rates with ICPi are also frequently associated with autoimmune side effects, so-called immune-related adverse events (irAEs), which can involve virtually any organ system and mirror classical autoimmune diseases. Recent studies revealed that around 5-20% of patients treated with ICPi experience rheumatic irAEs covering the full spectrum of inflammatory rheumatic diseases. This article summarizes the state of the art of knowledge with respect to diagnostics and management of this newly recognized disease entity in rheumatology.
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Braun GS, Kirschner M, Rübben A, Wahl RU, Amann K, Benesova K, Leipe J. [Side effects of novel cancer immunotherapies]. DER NEPHROLOGE 2020; 15:191-204. [PMID: 32351619 PMCID: PMC7189634 DOI: 10.1007/s11560-020-00424-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Systemic treatment with immune checkpoint inhibitors (ICI) has revolutionized the treatment of hematological and oncological diseases in recent years. The mechanism of action hinges on enhancing the natural ability of the immune system to eliminate malignant cells. The most important substances in this arena include inhibitors of PD‑1, PD-L1 and CTLA‑4. As a consequence, the spectrum of treatment-associated adverse reactions is shifting away from classical cytotoxic effects (e.g. pancytopenia and polyneuropathy) towards novel entities of immune-mediated complex diseases. These so-called immune-related adverse events (irAEs) can involve any organ system and mimic known classical autoimmune conditions. Timely recognition of irAEs is the key for rapid initiation of a suitable treatment and is especially challenging in the clinical routine as it requires an intensive interdisciplinary management. Nephrologists are particularly confronted with this kind of problem due to the highly interdisciplinary nature of their work. This article summarizes the broad spectrum of currently known renal and more frequently occuring non-renal forms of irAEs and aims to prime the reader on diagnostic and therapeutic options.
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Affiliation(s)
- G. S. Braun
- Klinik für Nieren- und Hochdruckkrankheiten, rheumatologische und immunologische Erkrankungen (Medizinische Klinik II), Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - M. Kirschner
- Klinik für Hämatologie, Onkologie, Hämostaseologie und Stammzelltransplantation (Medizinische Klinik IV), Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - A. Rübben
- Klinik für Dermatologie und Allergologie – Hautklinik, Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - R. U. Wahl
- Klinik für Dermatologie und Allergologie – Hautklinik, Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - K. Amann
- Institut für Pathologie, Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - K. Benesova
- Sektion Rheumatologie, Innere Medizin V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - J. Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim, Deutschland
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, München, Deutschland
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43
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Kostine M, Finckh A, Bingham CO, Visser K, Leipe J, Schulze-Koops H, Choy EH, Benesova K, Radstake TRDJ, Cope AP, Lambotte O, Gottenberg JE, Allenbach Y, Visser M, Rusthoven C, Thomasen L, Jamal S, Marabelle A, Larkin J, Haanen JBAG, Calabrese LH, Mariette X, Schaeverbeke T. EULAR points to consider for the diagnosis and management of rheumatic immune-related adverse events due to cancer immunotherapy with checkpoint inhibitors. Ann Rheum Dis 2020; 80:36-48. [PMID: 32327425 PMCID: PMC7788064 DOI: 10.1136/annrheumdis-2020-217139] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
Background Rheumatic and musculoskeletal immune-related adverse events (irAEs) are observed in about 10% of patients with cancer receiving checkpoint inhibitors (CPIs). Given the recent emergence of these events and the lack of guidance for rheumatologists addressing them, a European League Against Rheumatism task force was convened to harmonise expert opinion regarding their identification and management. Methods First, the group formulated research questions for a systematic literature review. Then, based on literature and using a consensus procedure, 4 overarching principles and 10 points to consider were developed. Results The overarching principles defined the role of rheumatologists in the management of irAEs, highlighting the shared decision-making process between patients, oncologists and rheumatologists. The points to consider inform rheumatologists on the wide spectrum of musculoskeletal irAEs, not fulfilling usual classification criteria of rheumatic diseases, and their differential diagnoses. Early referral and facilitated access to rheumatologist are recommended, to document the target organ inflammation. Regarding therapeutic, three treatment escalations were defined: (1) local/systemic glucocorticoids if symptoms are not controlled by symptomatic treatment, then tapered to the lowest efficient dose, (2) conventional synthetic disease-modifying antirheumatic drugs, in case of inadequate response to glucocorticoids or for steroid sparing and (3) biological disease-modifying antirheumatic drugs, for severe or refractory irAEs. A warning has been made on severe myositis, a life-threatening situation, requiring high dose of glucocorticoids and close monitoring. For patients with pre-existing rheumatic disease, baseline immunosuppressive regimen should be kept at the lowest efficient dose before starting immunotherapies. Conclusion These statements provide guidance on diagnosis and management of rheumatic irAEs and aim to support future international collaborations.
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Affiliation(s)
- Marie Kostine
- Rheumatology, University Hospital of Bordeaux, Bordeaux, France
| | - Axel Finckh
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | | | - Karen Visser
- Rheumatology, Haga Hospital, Den Haag, The Netherlands
| | - Jan Leipe
- Department of Medicine V, Division of Rheumatology, University Hospital Centre, Mannheim, Germany.,Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Hendrik Schulze-Koops
- Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Ernest H Choy
- Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
| | | | | | - Andrew P Cope
- Academic Department of Rheumatology, King's College London, London, UK
| | - Olivier Lambotte
- Internal Medicine and Clinical Immunology, Hopital Bicetre, Le Kremlin-Bicetre, France
| | | | - Yves Allenbach
- Internal Medicine and Clinical Immunology, Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France
| | - Marianne Visser
- EULAR PARE Patient Research Partners, Amsterdam, The Netherlands
| | - Cindy Rusthoven
- EULAR PARE Patient Research Partners, Amsterdam, The Netherlands
| | | | - Shahin Jamal
- Rheumatology, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - James Larkin
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - John B A G Haanen
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | | | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, Le Kremlin Bicêtre, France.,3Université Paris-Sud, Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
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44
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Steven NM, Fisher BA. Management of rheumatic complications of immune checkpoint inhibitor therapy - an oncological perspective. Rheumatology (Oxford) 2020; 58:vii29-vii39. [PMID: 31816079 PMCID: PMC6900910 DOI: 10.1093/rheumatology/kez536] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (CPIs) are an effective treatment for many cancers but cause diverse immune-related adverse events (IrAEs). Rheumatological IrAEs include arthralgia, arthritis, tenosynovitis, myositis, polymyalgia rheumatica and sicca syndrome. CPI use can unmask RA as well as causing flares of prior autoimmune or connective tissue disease. Oncologists categorize and grade IrAEs using the Common Terminology Criteria for Adverse Events and manage them according to international guidelines. However, rheumatological events are unfamiliar territory: oncologists need to work with rheumatologists to elicit and assess symptoms, signs, results of imaging and autoantibody testing and to determine the use of steroids and DMARDs. Myositis may overlap with myasthenic crisis and myocarditis and can be life-threatening. Treatment should be offered on balance of risk and benefit, including whether to continue CPI treatment and recognizing the uncertainty over whether glucocorticoids and DMARDs might compromise cancer control.
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Affiliation(s)
- Neil M Steven
- Institute of Immunology and Immunotherapy, Birmingham, UK.,Cancer Centre, University Hospital Birmingham, Birmingham, UK
| | - Benjamin A Fisher
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,National Institute of Health Research Birmingham Biomedical Research Centre and Department of Rheumatology, University Hospital Birmingham, Birmingham, UK
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45
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Kostine M, Truchetet ME, Schaeverbeke T. Clinical characteristics of rheumatic syndromes associated with checkpoint inhibitors therapy. Rheumatology (Oxford) 2020; 58:vii68-vii74. [PMID: 31816082 PMCID: PMC6900916 DOI: 10.1093/rheumatology/kez295] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/31/2019] [Indexed: 12/21/2022] Open
Abstract
Compared with conventional cancer therapies, the spectrum of toxicities observed with checkpoint inhibitors is unique and can affect any organ system. Arthralgia and myalgia were by far the most commonly reported rheumatic immune-related adverse events in clinical trials, and there is now a growing number of case series and reports describing clinical features of de novo rheumatic immune-related adverse events, which will be the focus of this review. Some patients develop genuine classic rheumatic and musculoskeletal diseases, but a number of rheumatic immune-related adverse events mimic rheumatic and musculoskeletal diseases with atypical features, mainly polymyalgia rheumatica, rheumatoid arthritis and myositis, as well as several systemic conditions, including sicca syndrome, vasculitis, sarcoidosis, systemic sclerosis and lupus.
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Affiliation(s)
- Marie Kostine
- Department of Rheumatology, Bordeaux University Hospital, Bordeaux, France
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46
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Leipe J, Mariette X. Management of rheumatic complications of ICI therapy: a rheumatology viewpoint. Rheumatology (Oxford) 2020; 58:vii49-vii58. [PMID: 31816078 PMCID: PMC6900914 DOI: 10.1093/rheumatology/kez360] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/05/2019] [Indexed: 12/13/2022] Open
Abstract
Since immune checkpoint inhibitors became the standard of care for an increasing number of indications, more patients have been exposed to these drugs and physicians are more challenged with the management of a unique spectrum of immune-related adverse events (irAEs) associated with immune checkpoint inhibitors. Those irAEs of autoimmune or autoinflammatory origin, or both, can involve any organ or tissue, but most commonly affect the dermatological, gastrointestinal and endocrine systems. Rheumatic/systemic irAEs seem to be less frequent (although underreporting in clinical trials is probable), but information on their management is highly relevant given that they can persist longer than other irAEs. Their management consists of anti-inflammatory treatment including glucocorticoids, synthetic and biologic immunomodulatory/immunosuppressive drugs, symptomatic therapies as well as holding or, rarely, discontinuation of immune checkpoint inhibitors. Here, we summarize the management of rheumatic/systemic irAEs based on data from clinical trials but mainly from published case reports and series, contextualize them and propose perspectives for their treatment.
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Affiliation(s)
- Jan Leipe
- Department of Medicine V, Division of Rheumatology, University Medical Centre, Mannheim, Munich, Germany.,Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Xavier Mariette
- Department of Rheumatology, Université Paris-Sud, AP-HP, Hôpitaux Universitaires Paris-Sud, Centre for Immunology of Viral Infections and Autoimmune Diseases, INSERM UMR1184, Le Kremlin Bicêtre, France
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47
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Cappelli LC, Thomas MA, Bingham CO, Shah AA, Darrah E. Immune checkpoint inhibitor-induced inflammatory arthritis as a model of autoimmune arthritis. Immunol Rev 2020; 294:106-123. [PMID: 31930524 PMCID: PMC7047521 DOI: 10.1111/imr.12832] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023]
Abstract
The development of inflammatory arthritis in patients receiving immune checkpoint inhibitor therapy is increasingly recognized due to the growing use of these drugs for the treatment of cancer. This represents an important opportunity not only to define the mechanisms responsible for the development of this immune-related adverse event and to ultimately predict or prevent its development, but also to provide a unique window into early events in the development of inflammatory arthritis. Knowledge gained through the study of this patient population, for which the inciting event is known, could shed light into the pathogenesis of autoimmune arthritis. This review will highlight the clinical and immunologic features of these entities to define common elements for future study.
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Affiliation(s)
- Laura C. Cappelli
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
| | - Mekha A. Thomas
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
| | - Clifton O. Bingham
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
| | - Ami A. Shah
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
| | - Erika Darrah
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
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48
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Papaxoinis G, Anastasopoulou A, Laskari K, Diamantopoulos P, Benopoulou O, Gogas H. A case report of immune-mediated arthritis in a patient with cutaneous melanoma receiving checkpoint inhibition therapy. Medicine (Baltimore) 2020; 99:e19439. [PMID: 32150095 PMCID: PMC7478575 DOI: 10.1097/md.0000000000019439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/19/2019] [Accepted: 02/06/2020] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) represent an important advance in the treatment of melanoma. ICIs may induce autoimmune phenomena caused by concurrent activation of the immune system against normal cells. During the last years, cases of musculoskeletal side effects, especially immune-mediated arthritis (IA), have been increasingly reported. PATIENT CONCERNS We present a 59-year-old woman, who was treated with pembrolizumab for a relapsed BRAF V600E mutated cutaneous malignant melanoma. The patient presented with right knee arthritis on week 30. DIAGNOSIS The erythrocyte sedimentation rate and serum C-reactive protein levels were elevated, while rheumatoid factor and anti-cyclic citrullinated peptide antibodies were negative. Imaging confirmed the presence of fluid mainly in the suprapatellar bursa. Synovial fluid analysis revealed an inflammatory effusion, while other etiologies of inflammatory arthritis were excluded. INTERVENTIONS Arthritis improved with an intra-articular injection of 8 mg dexamethasone. Twelve days later the arthritis relapsed in both knees, and although it was resistant to nonsteroidal anti-inflammatory treatment, it improved with systemic steroids. Tapering of methylprednisolone dose was feasible with the coadministration of leflunomide and subsequently hydroxychloroquine. OUTCOMES Arthritis resolved and the patient is free of complications and disease activity 20 months after the initiation of the second line systemic treatment. CONCLUSIONS We present an unusual case of IA associated with pembrolizumab treatment. The originality of the current report is based on the late occurrence, the monoarticular initial distribution, and uncommon location of IA at the knee.
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Affiliation(s)
- George Papaxoinis
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Amalia Anastasopoulou
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Katerina Laskari
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, University of Athens, Athens, Greece
| | - Panagiotis Diamantopoulos
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Olga Benopoulou
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Helen Gogas
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens
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Kobak S. Pembrolizumab-Induced Seronegative Arthritis and Fasciitis in a Patient with Lung Adenocarcinoma. Curr Drug Saf 2020; 14:225-229. [PMID: 31132977 PMCID: PMC6864613 DOI: 10.2174/1574886314666190528121039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/14/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (CPIs) are new promising anti-cancer drugs that block negative costimulation of T-cells leading to an enhanced anti-tumor immune response. Pembrolizumab, an a monoclonal antibody, targeting the programmed cell death protein 1 (PD-1) pathway. CPIs have been associated with a number of immune-related adverse events (AEs), including musculoskeletal and rheumatic disease. OBJECTIVE To present a case with lung adenocarcinoma treated with pembrolizumab, which developed inflammatory arthritis and fasciitis. CASE REPORT A 73-year-old male patient was referred to the rheumatology outpatient clinic with complaints of pain in the pretibial area, pain and swelling in both ankles joints and the right fırst metacarpophalangeal (MCP) joint. Three months ago he had diagnosed with lung adenocarcinoma and pembrolizumab was started. Locomotor system complaints were started after receiving two infusions of pembrolizumab. Physical examination revealed both ankle arthritis, mild edema in the pretibial region, tenderness in the muscles and arthritis in the right fırst MCP joint. Laboratory examinations showed mild acute phase reactants elevation. Lower extremity MRI showed diffuse edema in both gastrocnemius muscle and fascia, compatible with fasciitis. Pembrolizumab-related fasciitis and seronegative arthritis were diagnosed. Low dose corticosteroid was started and a significant regression was observed in the patient's complaints. CONCLUSION Inflammatory myositis with fasciitis and inflammatory arthritis in lower extremities appears to be a new adverse effect of pembrolizumab therapy.
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Affiliation(s)
- Senol Kobak
- Istinye University Faculty of Medicine, LIV Hospital, Department of Rheumatology, Istanbul, Turkey
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50
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Abstract
Links between autoimmune rheumatic diseases and cancer continue to be elucidated. In this review, we explore this complex, bidirectional relationship. First, the increased risk of cancer across the breadth of the autoimmune rheumatic diseases is described. The magnitude of risk and types of tumors seen can differ by the type of autoimmune disease, timing of disease course, and even clinical and laboratory features within a particular autoimmune disease, suggesting that targeted cancer screening strategies can be considered. Multiple mechanisms linking autoimmune rheumatic diseases and cancer are discussed, including the development of autoimmunity in the context of naturally occurring anti-tumor immune responses and malignancy arising in the context of inflammation and damage from autoimmunity. Immunosuppression for rheumatic disease can increase risk for certain types of cancers. Finally, immune checkpoint inhibitors, a type of cancer immunotherapy, which cause a variety of inflammatory syndromes of importance to rheumatologists, are reviewed.
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Affiliation(s)
- Laura C Cappelli
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Arthritis Center, Baltimore, MD, 21224, USA.
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Center Tower, Suite 4100, Baltimore, MD, 21224, USA.
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