1
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Kurnik M, Peter F, Matej P. Tocilizumab and CytoSorb for delayed severe cytokine release syndrome after ipilimumab plus nivolumab immunotherapy. Immunotherapy 2024:1-11. [PMID: 39016056 DOI: 10.1080/1750743x.2024.2370180] [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: 11/30/2023] [Accepted: 06/17/2024] [Indexed: 07/18/2024] Open
Abstract
Cytokine release syndrome (CRS) is immune dysregulation phenomenon that is associated with immune checkpoint inhibitors. It is still difficult to distinguish CRS from other dangerous, acute and life-threatening medical disorders.We present a case of delayed grade 4 CRS following treatment of lung adenocarcinoma with ipilimumab plus nivolumab that warranted intensive care level treatment with abundant fluid resuscitation, two-tire vasopressor support, high-flow nasal oxygenation, corticosteroids in high dosages, as well as sustained low-efficiency daily diafiltration with CytoSorb hemadsorption and tocilizumab. Initial treatment of presumed septic shock of unknown origin did not yield results.After initiation of corticosteroids and particularly CytoSorb hemadsorption and tocilizumab, prompt clinical and laboratory improvement was observed.
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Affiliation(s)
- Marko Kurnik
- General Hospital Celje, Department of Internal Intensive Medicine, Celje, Slovenia
| | - Fazarinc Peter
- General Hospital Celje, Department of Hematology & Oncology, Celje, Slovenia
| | - Podbregar Matej
- General Hospital Celje, Department of Internal Intensive Medicine, Celje, Slovenia
- University of Ljubljana, Medical Faculty, Ljubljana, Slovenia
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2
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Ntwali F, Gilliaux Q, Honoré PM. Nivolumab-Induced Cytokine Release Syndrome: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e941835. [PMID: 38625840 PMCID: PMC11034389 DOI: 10.12659/ajcr.941835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 03/03/2024] [Accepted: 01/17/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND CRS (cytokine release syndrome) is a massive activation of the inflammatory system characterized by a supra-physiological rate of inflammatory cytokines. The interleukin 6 cytokine plays a central role in CRS. The main clinical sign of CRS is fever, but CRS can lead to multiple organ failure in severe cases. CRS is usually described in sepsis, more recently in SARS COV-2 infection, and in chimeric antigen receptor T-cell therapy. However, it can also be associated with immune checkpoint inhibitors (ICIs), which is infrequently described. ICI have growing indications and can lead to CRS by causing an uncontrolled activation of the immune system. There are currently no treatment guidelines for ICI-induced CRS. CASE REPORT We report a rare case of grade 3 CRS induced by nivolumab associated with 5-fluorouracil and oxaliplatin for gastric cancer. The patient was 65-year-old man with an adenocarcinoma of the cardia. CRS developed during the tenth course of treatment and was characterized by fever, hypotension requiring vasopressors, hypoxemia, acute kidney injury, and thrombopenia. The patient was transferred quickly to the Intensive Care Unit. He was treated for suspected sepsis, but it was ruled out after multiple laboratory examinations. There was rapid resolution after infusion of hydrocortisone. CONCLUSIONS The use of ICIs is expanding. Nivolumab-induced CRS is rarely described but can be severe and lead to multiple organ dysfunction; therefore, intensive care practitioners should be informed about this adverse effect. More studies are needed to better understand this condition and establish treatment guidelines.
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Affiliation(s)
- Francis Ntwali
- Intensive Care Unit, UCL Namur University Hospital, Yvoir, Belgium
| | - Quentin Gilliaux
- Department of Oncology, UCL Namur University Hospital, Yvoir, Belgium
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3
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Zhang Y, Wen X, OuYang Y, Hu Y, Fang X, Zhang J, Yuan Y. Severe cytokine release syndrome induced by immune checkpoint inhibitors in cancer patients - A case report and review of the literature. Heliyon 2024; 10:e24380. [PMID: 38293388 PMCID: PMC10826737 DOI: 10.1016/j.heliyon.2024.e24380] [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: 11/20/2023] [Revised: 12/20/2023] [Accepted: 01/08/2024] [Indexed: 02/01/2024] Open
Abstract
Cytokine release syndrome (CRS) can be induced by immune checkpoint inhibitors (ICIs). Although the incidence of CRS is low, it is often underreported. Here, we report two severe CRS cases and summarize and review 51 patients with ICI-induced CRS to explore the possible contributing factors to the disease prognosis and provide assistance for therapy. Our analysis found that the population with ICI-induced CRS consists mainly of male patients with an average age of 61.74 years. The primary malignant tumor type was lung cancer, and the clinical stage of most patients was stage IV. Notably, patients who experience a longer time to CRS onset, higher IL-6 levels, and lower platelet counts may be more likely to develop severe CRS. Cardiovascular, respiratory, neurological, and coagulation toxicities are more common in higher-grade CRS and may serve as markers for patient experiencing ICU admission, oxygen supplementation, hypotension, high-dose vasopressors usage, and intubation.
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Affiliation(s)
- Yujing Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
| | - Xiaoyue Wen
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
| | - Yaqi OuYang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
| | - Yingying Hu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
| | - Xiangzhi Fang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
| | - Jiancheng Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
| | - Yin Yuan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, PR China
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4
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Yoshimura A, Yamamoto Y, Nishikawa T, Fujita M, Inoue T, Kondo F, Hayashi T, Kawamura N, Nagahara A, Nakai Y, Nakayama M, Nishimura K. Relapsing cytokine release syndrome in a patient with metastatic renal cell carcinoma treated with pembrolizumab and axitinib therapy. Int Cancer Conf J 2024; 13:26-32. [PMID: 38187183 PMCID: PMC10764692 DOI: 10.1007/s13691-023-00630-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/10/2023] [Indexed: 01/09/2024] Open
Abstract
As immune checkpoint inhibitors become more widely available, the optimal management of immune-related adverse events (irAEs) is becoming increasingly important. Although irAEs are diverse, reports on cytokine release syndrome are rare. Here, we report a case of a 48-year-old man with relapsing cytokine release syndrome after receiving pembrolizumab and axitinib combination therapy for metastatic renal cell carcinoma. During dose reduction of prednisolone for immune-related hepatitis on day 33 after starting pembrolizumab plus axitinib, the patient suddenly developed abdominal pain, and a few hours later became hypotensive and poorly oxygenated. Despite the use of a ventilator and high doses of catecholamines, blood pressure and oxygenation could not be maintained. Extracorporeal membrane oxygenation and intra-aortic balloon pumping were also administered. The cytokine release syndrome (CRS) was treated with tocilizumab, and his general condition improved. Lower-grade CRS relapsed four times despite a moderate dose of oral prednisolone with mycophenolate mofetil or tacrolimus. After gradual reduction in prednisolone over 5 months, the patient was discharged from the hospital. Partial remission of renal cell carcinoma continued for 21 months, and salvage radical nephrectomy was performed. The patient remained disease-free without the need for further treatment 9 months after surgery.
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Affiliation(s)
- Akihiro Yoshimura
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Yoshiyuki Yamamoto
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Tatsuya Nishikawa
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Takako Inoue
- Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Fuki Kondo
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Takuji Hayashi
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Norihiko Kawamura
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Akira Nagahara
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Yasutomo Nakai
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Masashi Nakayama
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Kazuo Nishimura
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
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5
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Shah D, Soper B, Shopland L. Cytokine release syndrome and cancer immunotherapies - historical challenges and promising futures. Front Immunol 2023; 14:1190379. [PMID: 37304291 PMCID: PMC10248525 DOI: 10.3389/fimmu.2023.1190379] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Cancer is the leading cause of death worldwide. Cancer immunotherapy involves reinvigorating the patient's own immune system to fight against cancer. While novel approaches like Chimeric Antigen Receptor (CAR) T cells, bispecific T cell engagers, and immune checkpoint inhibitors have shown promising efficacy, Cytokine Release Syndrome (CRS) is a serious adverse effect and remains a major concern. CRS is a phenomenon of immune hyperactivation that results in excessive cytokine secretion, and if left unchecked, it may lead to multi-organ failure and death. Here we review the pathophysiology of CRS, its occurrence and management in the context of cancer immunotherapy, and the screening approaches that can be used to assess CRS and de-risk drug discovery earlier in the clinical setting with more predictive pre-clinical data. Furthermore, the review also sheds light on the potential immunotherapeutic approaches that can be used to overcome CRS associated with T cell activation.
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Affiliation(s)
- Deep Shah
- In vivo Services, The Jackson Laboratory, Sacramento, CA, United States
| | - Brian Soper
- Technical Information Services, The Jackson Laboratory, Bar Harbor, ME, United States
| | - Lindsay Shopland
- In vivo Services, The Jackson Laboratory, Sacramento, CA, United States
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6
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Liu LL, Skribek M, Harmenberg U, Gerling M. Systemic inflammatory syndromes as life-threatening side effects of immune checkpoint inhibitors: case report and systematic review of the literature. J Immunother Cancer 2023; 11:jitc-2022-005841. [PMID: 36878533 PMCID: PMC9990684 DOI: 10.1136/jitc-2022-005841] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 03/08/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are associated with a wide range of immune-related adverse events. As oncological indications for ICIs widen, their rare side effects become increasingly visible in clinical practice and impact therapy decisions.Here, we report a rare case of early-onset, mild cytokine release syndrome (CRS) in a patient who received ICIs for a metastasized renal cell carcinoma, which led to treatment discontinuation.We further provide a systematic review of the literature of CRS and related life-threatening side effects of ICI treatment, such as hemophagocytic lymphohistiocytosis (HLH). We searched Medline, Embase and the Web of Science Core Collection from inception to October 2021 for reports on CRS, cytokine storm, macrophage activation syndrome, HLH, and related hyperinflammatory disorders in patients with solid cancers receiving ICIs. We found n=1866 articles, which were assessed for eligibility independently by two examiners. Of those, n=49 articles reporting on n=189 individuals were eligible for review. We found that the median time from last infusion to the occurrence of CRS/HLH was approximately nine days, while the onset of symptoms varied from immediately after infusion to one month after treatment. Most patients were treated with either corticosteroids or the anti-interleukin 6 (IL-6) antibody tocilizumab, and although the majority of patients recovered, a few cases were fatal. Concomitant IL-6 and ICI treatment were reported as beneficial for both the antitumoral effect and for limiting side effects. Data from international pharmacovigilance databases underscored that ICI-related CRS and HLH are rare events, but we identified significant differences in reported frequencies, which might suggest substantial under-reporting.The results from this first systematic review of CRS/HLH due to ICI therapy highlight that life-threatening systemic inflammatory complications of ICIs are rare and might be associated with fatal outcome in approximately 10% of patients. Limited data support the use of IL-6 inhibitors in combination with ICIs to augment the antitumoral effect and reduce hyperinflammation.
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Affiliation(s)
- Lisa L Liu
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden .,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Skribek
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden.,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Harmenberg
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden.,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Gerling
- Theme Cancer, Karolinska University Hospital, Stockholm, Sweden .,Department of Biosciences and Nutrition, Karolinska Institute, Stockholm, Sweden
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7
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Lhuillier M, Brière M, Artifoni M, Chapal M, Peuvrel L, Saint-Jean M. Cemiplimab-induced cytokine-release syndrome: second case reported and review of the literature. Immunotherapy 2023; 15:229-234. [PMID: 36789558 DOI: 10.2217/imt-2021-0306] [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: 02/16/2023] Open
Abstract
Cemiplimab, a human monoclonal antibody directed against PD-1, has provided more options in the treatment of locally advanced or metastatic cutaneous squamous-cell carcinoma at an unresectable state. Immune checkpoint inhibitors can induce several unfavorable reactions generally referred to as immune-related adverse effects. Cytokine-release syndrome is an immune-related adverse event that is infrequent and not well known. Diagnosis is difficult because of the unspecific symptoms (e.g., fever, hypotension) but it can also be life threatening. The authors report the case of a 62-year-old treated by cemiplimab for a cutaneous squamous-cell carcinoma of the diaper fold with iliac and inguinal lymph node extension. He presented with severe cytokine-release syndrome, concluding with the discontinuation of cemiplimab.
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Affiliation(s)
- Marine Lhuillier
- Department of Medical Oncology, ICO Cancer Center, Saint-Herblain, 44800, France
| | - Magali Brière
- Department of Infectious Disease, ICO Cancer Center, Saint-Herblain, 44800, France
| | - Mathieu Artifoni
- Department of Internal Medicine, University Hospital of Nantes, 44000, France
| | - Marion Chapal
- Departement of Nephrology, Hospital of Vendée, La Roche-Sur-Yon, 85000, France
| | - Lucie Peuvrel
- Department of Medical Oncology, ICO Cancer Center, Saint-Herblain, 44800, France
| | - Mélanie Saint-Jean
- Department of Medical Oncology, ICO Cancer Center, Saint-Herblain, 44800, France
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8
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Ni Y, Low JT, Silke J, O'Reilly LA. Digesting the Role of JAK-STAT and Cytokine Signaling in Oral and Gastric Cancers. Front Immunol 2022; 13:835997. [PMID: 35844493 PMCID: PMC9277720 DOI: 10.3389/fimmu.2022.835997] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/16/2022] [Indexed: 12/12/2022] Open
Abstract
When small proteins such as cytokines bind to their associated receptors on the plasma membrane, they can activate multiple internal signaling cascades allowing information from one cell to affect another. Frequently the signaling cascade leads to a change in gene expression that can affect cell functions such as proliferation, differentiation and homeostasis. The Janus kinase-signal transducer and activator of transcription (JAK-STAT) and the tumor necrosis factor receptor (TNFR) are the pivotal mechanisms employed for such communication. When deregulated, the JAK-STAT and the TNF receptor signaling pathways can induce chronic inflammatory phenotypes by promoting more cytokine production. Furthermore, these signaling pathways can promote replication, survival and metastasis of cancer cells. This review will summarize the essentials of the JAK/STAT and TNF signaling pathways and their regulation and the molecular mechanisms that lead to the dysregulation of the JAK-STAT pathway. The consequences of dysregulation, as ascertained from founding work in haematopoietic malignancies to more recent research in solid oral-gastrointestinal cancers, will also be discussed. Finally, this review will highlight the development and future of therapeutic applications which modulate the JAK-STAT or the TNF signaling pathways in cancers.
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Affiliation(s)
- Yanhong Ni
- Central Laboratory, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jun T Low
- Inflammation Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - John Silke
- Inflammation Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Lorraine A O'Reilly
- Inflammation Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
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9
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Braun TM, Mercier F. Extending the Continual Reassessment Method to accommodate step-up dosing in Phase I trials. Stat Med 2022; 41:3975-3990. [PMID: 35662077 PMCID: PMC9546169 DOI: 10.1002/sim.9487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
The Continual Reassessment Method (CRM) was developed for Phase I trials to identify a maximum‐tolerated dose of an agent using a design in which each participant is treated with a single administration of the agent. We propose an extension of the CRM in which participants receive multiple administrations of an agent using a so‐called step‐up dosing procedure in which participants receive one or more administrations of lower doses of the agent before they receive their penultimate dose. We use methods developed for the CRM to model the probability of DLT for each administration, which leads to the use of conditional probability models to model the joint probability of DLT across multiple administrations. We compare our approach to two existing methods that use time‐to‐event modeling methods for modeling the probability of DLT. We demonstrate through simulations that our approach has operating characteristics similar to existing methods, but due to its foundations in the CRM, ours is simpler to implement than existing approaches and is therefore more likely to be adopted in practice.
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Affiliation(s)
- Thomas M. Braun
- Department of BiostatisticsUniversity of MichiganAnn ArborMichiganUSA
| | - Francois Mercier
- Department of BiostatisticsRoche Innovation CentreBaselSwitzerland
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10
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Kataoka S, Moriguchi M, Okishio S, Takahashi A, Okuda K, Seko Y, Umemura A, Yamaguchi K, Miyagawa-Hayashino A, Itoh Y. Re-administration of nivolumab after immune checkpoint inhibitor-induced cholangitis: the first reported case. Clin J Gastroenterol 2022; 15:467-474. [PMID: 35201598 DOI: 10.1007/s12328-022-01590-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/05/2022] [Indexed: 12/19/2022]
Abstract
Immune checkpoint inhibitors (ICIs) cause various immune-related adverse events (irAEs). We encountered a patient in whom nivolumab was re-administered effectively and safely treat laryngeal cancer after nivolumab-induced cholangitis. A 60-year-old man with metastatic laryngeal squamous cell carcinoma received 3rd-line treatment with nivolumab. After the 8th cycle of chemotherapy, laboratory tests revealed grade 3 elevations of gamma-glutamyl transpeptidase and alkaline phosphatase. Computed tomography and endoscopic retrograde cholangiopancreatography showed diffuse hypertrophy, dilation of bile ducts, and intrahepatic bile ducts with irregular walls and mild stenosis. The histologic findings of a liver biopsy revealed portal inflammation and cholangitis, mainly composed of T cell infiltration. We diagnosed nivolumab-induced cholangitis and administered 30 mg of prednisolone (0.5 mg/kg) and ursodeoxycholic acid (600 mg) per day. Although we initiated 4th-line cytotoxic anticancer drug after the cholangitis improved, the laryngeal cancer progressed rapidly. Based on the improvement in hematologic parameters, radiologic imaging, and pathologic findings, we cautiously restarted nivolumab. During the 30 months after re-administration of nivolumab, the cholangitis did not recur and the disease was well-controlled.
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Affiliation(s)
- Seita Kataoka
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Michihisa Moriguchi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Shinya Okishio
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Aya Takahashi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Keiichiro Okuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuya Seko
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Atushi Umemura
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Kanji Yamaguchi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Aya Miyagawa-Hayashino
- Departoment of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
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11
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McDaniel MM, Chawla AS, Jain A, Meibers HE, Saha I, Gao Y, Jain V, Roskin K, Way SS, Pasare C. Effector memory CD4 + T cells induce damaging innate inflammation and autoimmune pathology by engaging CD40 and TNFR on myeloid cells. Sci Immunol 2022; 7:eabk0182. [PMID: 35061504 PMCID: PMC9036191 DOI: 10.1126/sciimmunol.abk0182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cytokine storm and sterile inflammation are common features of T cell-mediated autoimmune diseases and T cell-targeted cancer immunotherapies. Although blocking individual cytokines can mitigate some pathology, the upstream mechanisms governing overabundant innate inflammatory cytokine production remain unknown. Here, we have identified a critical signaling node that is engaged by effector memory T cells (TEM) to mobilize a broad proinflammatory program in the innate immune system. Cognate interactions between TEM and myeloid cells led to induction of an inflammatory transcriptional profile that was reminiscent, yet entirely independent, of classical pattern recognition receptor (PRR) activation. This PRR-independent "de novo" inflammation was driven by preexisting TEM engagement of both CD40 and tumor necrosis factor receptor (TNFR) on myeloid cells. Cytokine toxicity and autoimmune pathology could be completely rescued by ablating these pathways genetically or pharmacologically in multiple models of T cell-driven inflammation, indicating that TEM instruction of the innate immune system is a primary driver of associated immunopathology. Thus, we have identified a previously unknown trigger of cytokine storm and autoimmune pathology that is amenable to therapeutic interventions.
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Affiliation(s)
- Margaret M. McDaniel
- Immunology Graduate Program, University of Texas Southwestern Medical Center at Dallas, TX 75390,Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Amanpreet Singh Chawla
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Aakanksha Jain
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Hannah E. Meibers
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Immunology Graduate Program, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH 45220,Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Irene Saha
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Yajing Gao
- Immunology Graduate Program, University of Texas Southwestern Medical Center at Dallas, TX 75390
| | - Viral Jain
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, 35233,Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Krishna Roskin
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH 45220
| | - Sing Sing Way
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH 45220
| | - Chandrashekhar Pasare
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Center for Inflammation and Tolerance, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH 45220,Corresponding Author:
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Immune-related cholangitis induced by immune checkpoint inhibitors: a systematic review of clinical features and management. Eur J Gastroenterol Hepatol 2021; 33:e858-e867. [PMID: 34482313 PMCID: PMC8734631 DOI: 10.1097/meg.0000000000002280] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AIMS Immune checkpoint inhibitors (ICIs) improve the survival of patients with advanced tumors. However, immune-related adverse events limit the use of ICIs. Although liver toxicity has been concerned gradually, little is known about bile duct injury associated with ICIs. Hence, this review aims to describe clinicopathological features, imaging, and management of immune-mediated cholangitis (IMC) induced by ICIs. METHODS We retrieved the literature from the PubMed database for case reports and series of IMC induced by ICIs. IMC was then classified as small-ducts type, large-ducts type and mixed type. Biochemical parameters, pathological characteristics, imaging features, treatment and response were evaluated and compared among three patterns. RESULTS Fifty-three cases of IMC were enrolled. The median values of alkaline phosphatase and alanine transaminase of IMC were 1328 and 156 IU/L. The ALP level of the large-ducts type was higher than that of the small-ducts type (P = 0.021). The main pathological characteristics of small-ducts cholangitis were portal inflammation, bile duct injury and ductular reaction. The imaging features of large-duct cholangitis were bile duct dilatation, stenosis and bile duct wall thickening and irregularity. Forty-eight (90%) cases received immunosuppression therapy. Biliary enzymes reduced in 79% of cases receiving immunosuppression therapy, but only 8.5% of cases returned to normal. It took a long time for biliary enzymes to recover. CONCLUSIONS The clinicians should be aware of the possibility of IMC if the biliary enzymes increase significantly after the use of ICIs. The liver function can be improved partially by immunosuppressive therapy in the majority of IMC.
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Ciner AT, Hochster HS, August DA, Carpizo DR, Spencer KR. Delayed cytokine release syndrome after neoadjuvant nivolumab: a case report and literature review. Immunotherapy 2021; 13:1071-1078. [PMID: 34287029 DOI: 10.2217/imt-2020-0329] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Cytokine release syndrome (CRS) is an infrequently described immune-related adverse event of checkpoint inhibitors (CPI). CPI-induced CRS typically presents with fevers, hemodynamic instability and organ dysfunction within 2 weeks of the last treatment cycle. Case study: We report an unusual case of delayed and severe CRS occurring postoperatively in a patient with hepatic-limited metastatic colorectal cancer who received neoadjuvant immunotherapy. After a negative workup for alternative causes, he received prolonged corticosteroid treatment with symptom resolution. Conclusion: CPI-induced CRS can mimic sepsis and clinicians should maintain a high-index of suspicion to diagnose this immune-related adverse event early and initiate appropriate treatment. As use of perioperative immunotherapy increases, the potential role of surgery to trigger CRS in this case warrants further investigation.
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Affiliation(s)
- Aaron T Ciner
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
| | - Howard S Hochster
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
| | - David A August
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
| | - Darren R Carpizo
- Department of Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Kristen R Spencer
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
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Cholangiopathy After Severe COVID-19: Clinical Features and Prognostic Implications. Am J Gastroenterol 2021; 116:1414-1425. [PMID: 33993134 DOI: 10.14309/ajg.0000000000001264] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/12/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 virus, is a predominantly respiratory tract infection with the capacity to affect multiple organ systems. Abnormal liver tests, mainly transaminase elevations, have been reported in hospitalized patients. We describe a syndrome of cholangiopathy in patients recovering from severe COVID-19 characterized by marked elevation in serum alkaline phosphatase (ALP) accompanied by evidence of bile duct injury on imaging. METHODS We conducted a retrospective study of COVID-19 patients admitted to our institution from March 1, 2020, to August 15, 2020, on whom the hepatology service was consulted for abnormal liver tests. Bile duct injury was identified by abnormal liver tests with serum ALP > 3x upper limit of normal and abnormal findings on magnetic resonance cholangiopacreatography. Clinical, laboratory, radiological, and histological findings were recorded in a Research Electronic Data Capture database. RESULTS Twelve patients were identified, 11 men and 1 woman, with a mean age of 58 years. Mean time from COVID-19 diagnosis to diagnosis of cholangiopathy was 118 days. Peak median serum alanine aminotransferase was 661 U/L and peak median serum ALP was 1855 U/L. Marked elevations of erythrocyte sedimentation rate, C-reactive protein, and D-dimers were common. Magnetic resonance cholangiopacreatography findings included beading of intrahepatic ducts (11/12, 92%), bile duct wall thickening with enhancement (7/12, 58%), and peribiliary diffusion high signal (10/12, 83%). Liver biopsy in 4 patients showed acute and/or chronic large duct obstruction without clear bile duct loss. Progressive biliary tract damage has been demonstrated radiographically. Five patients were referred for consideration of liver transplantation after experiencing persistent jaundice, hepatic insufficiency, and/or recurrent bacterial cholangitis. One patient underwent successful living donor liver transplantation. DISCUSSION Cholangiopathy is a late complication of severe COVID-19 with the potential for progressive biliary injury and liver failure. Further studies are required to understand pathogenesis, natural history, and therapeutic interventions.
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Urasaki T, Ono M, Mochizuki T, Takeda K, Nishizawa A, Fukagawa E, Fujiwara M, Komai Y, Kitano S, Yuasa T, Yonese J, Takahashi S. Case Report: A Case of Trimethoprim/Sulfamethoxazole-Triggered Hypotensive Shock: Cytokine Release Syndrome Related to Immune Checkpoint Inhibitors and Drug-Induced Hypersensitivity Syndrome. Front Oncol 2021; 11:681997. [PMID: 33996612 PMCID: PMC8121494 DOI: 10.3389/fonc.2021.681997] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Currently, only a few reports exist on the cytokine release syndrome (CRS) as one of the severe immune-related adverse events (irAEs) induced by immune checkpoint inhibitors (ICIs). Notably, it is very rare that grade 4 CRS related to ICI therapy overlaps with the drug-induced hypersensitivity syndrome (DiHS). A 46-year old woman with metastatic kidney cancer had grade 3 interstitial pneumonitis induced by four cycles of combination therapy of anti-programmed death-1 and anti-cytotoxic T lymphocyte-4 antibodies after right cytoreductive nephrectomy. Prophylactic administration of trimethoprim/sulfamethoxazole (TMP/SMX) was started concomitantly with prednisolone therapy to treat the interstitial pneumonitis. She developed hypotensive shock when reducing the dosage of prednisolone, and required intubation and ventilation using vasopressors at the intensive care unit. She subsequently exhibited prominent leukocytosis and an increased level of C-reactive protein, suggesting markedly increased cytokine levels. Interestingly, facial edema and erythema increased in association with pyrexia, leukocytosis, liver dysfunction, and renal failure, suggesting that she developed DiHS. She received hemodialysis three times, a plasma exchange, and anti-interleukin-6 therapy to treat severe renal dysfunction, a thrombotic thrombocytopenic purpura-suspected condition, and possible grade 4 CRS, respectively. Although these therapies did not elicit sufficient effects, high-dose administration of intravenous immunoglobulin was successful. With steroid mini-pulse therapy and the subsequent administration of prednisolone, she recovered successfully. To the best of our knowledge, this is the first report that ICIs and TMP/SMX can induce hypotensive shock accompanied with CRS and DiHS during immunosuppressive therapy for an irAE. Importantly, the prophylactic administration of TMP/SMX should be performed cautiously to avoid severe drug reactions such as CRS or DiHS.
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Affiliation(s)
- Tetsuya Urasaki
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makiko Ono
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiaki Mochizuki
- Department of Emergency Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koichi Takeda
- Department of Infectious Diseases, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Aya Nishizawa
- Department of Dermatology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Eri Fukagawa
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Motohiro Fujiwara
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshinobu Komai
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shigehisa Kitano
- Division of Cancer Immunotherapy Development, Advanced Medical Development Center, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Yuasa
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junji Yonese
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shunji Takahashi
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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Tsuruda T, Yoshikawa N, Kai M, Yamaguchi M, Toida R, Kodama T, Kajihara K, Kawabata T, Nakamura T, Sakata K, Hatakeyama K, Gi T, Asada Y, Tono T, Kitamura K, Ikeda R. The Cytokine Expression in Patients with Cardiac Complication after Immune Checkpoint Inhibitor Therapy. Intern Med 2021; 60:423-429. [PMID: 32963156 PMCID: PMC7925267 DOI: 10.2169/internalmedicine.5317-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We herein report the cytokine expression at different stages for three patients who developed cardiac complications after immune checkpoint inhibitor (ICI) therapy. Case 1 with biopsy-proven myocarditis showed increased levels of interleukin (IL)-8, monocyte chemotactic and activating factor, and granulocyte macrophage colony-stimulating factor (GM-CSF) when he developed Takotsubo cardiomyopathy. Case 2 with subclinical myocarditis showed predominant activation of IL-8 during the progressive clinical course. Case 3 with cytokine-releasing syndrome showed substantial activations of IL-6, IL-8, GM-CSF, and interferon-γ. Our data suggest the development of unique cytokine activation in individual patients with cardiac complications after ICI therapy.
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Affiliation(s)
- Toshihiro Tsuruda
- Department of Internal Medicine, Circulatory and Body Fluid Regulation, Faculty of Medicine, University of Miyazaki, Japan
| | - Naoki Yoshikawa
- Department of Pharmacy, University of Miyazaki Hospital, Japan
| | - Motoaki Kai
- Department of Internal Medicine, Circulatory and Body Fluid Regulation, Faculty of Medicine, University of Miyazaki, Japan
| | - Masashi Yamaguchi
- Department of Internal Medicine, Circulatory and Body Fluid Regulation, Faculty of Medicine, University of Miyazaki, Japan
| | - Reiko Toida
- Department of Cardiology, Chiyoda Hospital, Japan
| | | | - Kei Kajihara
- Department of Otolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Takayuki Kawabata
- Department of Otolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Takeshi Nakamura
- Department of Otolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Koji Sakata
- Department of Internal Medicine, Circulatory and Body Fluid Regulation, Faculty of Medicine, University of Miyazaki, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Japan
| | - Toshihiro Gi
- Department of Pathology, Faculty of Medicine, University of Miyazaki, Japan
| | - Yujiro Asada
- Department of Pathology, Faculty of Medicine, University of Miyazaki, Japan
| | - Tetsuya Tono
- Department of Otolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Kazuo Kitamura
- Department of Internal Medicine, Circulatory and Body Fluid Regulation, Faculty of Medicine, University of Miyazaki, Japan
| | - Ryuji Ikeda
- Department of Pharmacy, University of Miyazaki Hospital, Japan
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Metastasis to Appendix Presenting as Acute Appendicitis-A Rare Case Report and Review of Literature. J Gastrointest Cancer 2021; 52:1114-1118. [PMID: 33484435 DOI: 10.1007/s12029-021-00586-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
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18
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Normand CV, Zender HO, Staehli DM, Chouiter-Djebaili AF, John G. Acute cytokine release syndrome after a first dose of pembrolizumab as second-line treatment for metastatic, programmed death-ligand 1-positive, non-small-cell lung cancer. J Oncol Pharm Pract 2020; 27:1528-1533. [PMID: 33353504 DOI: 10.1177/1078155220980813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The use of programmed death-ligand 1 (PD-L1) checkpoint inhibitor therapy is expanding, although its adverse effects are not completely known. We report on a rare case of acute cytokine release syndrome related to pembrolizumab use in a patient with lung cancer. CASE REPORT A 79-year-old man with metastatic, PD-L1-positive, non-small-cell lung cancer developed a febrile condition associated with a systemic inflammatory response syndrome and suffered haemodynamic compromise four hours after the first intravenous administration of pembrolizumab. A thorough medical workup found no alternative cause and a grade 2 cytokine release syndrome (CRS) was diagnosed.Management and outcome: Aggressive fluid resuscitation and supportive therapy led to restitutio ad integrum. DISCUSSION Acute CRS after the administration of a PD-L1 inhibitor is infrequent but could be a fatal condition. Supportive treatment and, if necessary, corticosteroids should be considered.
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Affiliation(s)
- Clément V Normand
- Service of Internal Medicine, Department of Medicine, Réseau Hospitalier Neuchâtelois - La Chaux-de-Fonds, La Chaux-de-Fonds, Switzerland
| | - Hervé O Zender
- Service of Internal Medicine, Department of Medicine, Réseau Hospitalier Neuchâtelois - La Chaux-de-Fonds, La Chaux-de-Fonds, Switzerland
| | - Dominique M Staehli
- Service of Internal Medicine, Department of Medicine, Réseau Hospitalier Neuchâtelois - La Chaux-de-Fonds, La Chaux-de-Fonds, Switzerland
| | | | - Gregor John
- Service of Internal Medicine, Department of Medicine, Réseau Hospitalier Neuchâtelois - Pourtalès, Neuchâtel, Switzerland.,Department of Internal Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
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Kuo MC, Su PJ, Huang CC, Luo HL, Chiu TJ, Li SH, Wu CC, Liu TT, Cheng YT, Kang CH, Su YL. Safety and Efficacy of Immune Checkpoint Inhibitors for Patients With Metastatic Urothelial Carcinoma and End-Stage Renal Disease: Experiences From Real-World Practice. Front Oncol 2020; 10:584834. [PMID: 33330066 PMCID: PMC7729012 DOI: 10.3389/fonc.2020.584834] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are used widely for treating metastatic urothelial carcinoma (mUC). In practical settings, evidence is lacking on the efficacy of ICIs in some difficult-to-treat patients, such as those with end-stage renal disease (ESRD). Herein, we evaluate the safety and efficacy of ICIs for patients with mUC and ESRD. METHODS For this retrospective study, patients with mUC who were given ICIs at Kaohsiung Chang Gang Memorial Hospital and Linkou Chang Gung Memorial Hospital between April 2016 and November 2019 were consecutively enrolled. All clinicopathologic data, treatment responses, and adverse events were recorded. The immune-related adverse events (AEs), objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were compared between ESRD and non-ESRD groups. RESULTS In total, 129 patients with mUC were enrolled, with 11 patients categorized as the ESRD group. Among these patients with ESRD receiving ICIs, 7 of 11 (63.6%) had high-grade (grade ≥3) AEs, chiefly hematologic toxicity. Some rarely encountered AEs were noted, including toxic epidermal necrolysis, tuberculosis reactivation, ascites, and cytokine release syndrome. Patients in the ESRD group had numerically higher ORR (54.5% vs. 28.8%, p = 0.09), PFS (7.1 vs. 3.5 months, p = 0.42), and OS (not reached vs. 15.4 months) than the non-ESRD group. A multivariate Cox regression model demonstrated that leukocytosis (hazard ratio [HR]: 2.63; 95% confidence interval [CI]: 1.23-5.63; p = 0.01) and neutrophil-to-lymphocyte ratio (HR 2.91; 95% CI: 1.30-6.53; p = 0.01) were independent prognostic factors. CONCLUSION Administration of ICIs in patients with mUC and ESRD demonstrated a modest antitumor activity, and should be used with caution for increasing risk of hematologic toxicity.
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Affiliation(s)
- Ming-Chun Kuo
- Division of Hematology Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Po-Jung Su
- Division of Hematology Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chun-Chieh Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Hao-Lun Luo
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Tai-Jan Chiu
- Division of Hematology Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Shau-Hsuan Li
- Division of Hematology Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Chia-Che Wu
- Division of Hematology Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Ting-Ting Liu
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Yuan-Tso Cheng
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Chih-Hsiung Kang
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Yu-Li Su
- Division of Hematology Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
- Clinical Trial Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Gülsen A, Wedi B, Jappe U. Hypersensitivity reactions to biologics (part I): allergy as an important differential diagnosis in complex immune-derived adverse events*. ALLERGO JOURNAL 2020; 29:32-61. [PMID: 32546899 PMCID: PMC7289641 DOI: 10.1007/s15007-020-2550-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Askin Gülsen
- Division of Clinical and Molecular Allergology, Research Center Borstel, Borstel, Germany
| | - Bettina Wedi
- Klinik u. Poliklinik f. Dermatologie u. Venerologie, OE 6600 - Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Uta Jappe
- Klinische und Molekulare Allergologie - Forschungszentrum Borstel, Parkallee 35, 23845 Borstel, Germany
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21
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Hypersensitivity reactions to biologics (part I): allergy as an important differential diagnosis in complex immune-derived adverse events. ACTA ACUST UNITED AC 2020; 29:97-125. [PMID: 32421085 PMCID: PMC7223134 DOI: 10.1007/s40629-020-00126-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/31/2020] [Indexed: 12/15/2022]
Abstract
Purpose Biotechnological substances (BSs) are strongly relied upon to prevent rejection of transplanted organs, and to treat oncological, allergological, and other inflammatory diseases. Allergic reactions to partly foreign biologics can occur due to their potential immunogenicity. The severity of an immune response to a biological drug may range from no clinical significance to a severe, life-threatening anaphylactic reaction. Methods Detailed searches were performed on Pubmed, Web of Science, and Google Scholar to include all available publications. In addition, the Food and Drug Administration, the European Medicines Agency, and British Columbia Cancer Agency Drug Manual databases were screened for hypersensitivity reaction (HSR), infusion reaction, injection site reaction, urticaria, and anaphylaxis for individual BSs. Results Treatment with BSs can cause various types of HSR. These are mentioned in the literature with definitions such as allergic reactions, anaphylactoid reactions, anaphylaxis, HSR, infusion reactions, injection site reactions, cytokine release syndrome, and urticaria. Due to the overlap in signs and symptoms in the reported descriptions, it is not always possible to differentiate these reactions properly according to their pathomechanism. Similarly, many data reported as anaphylaxis actually describe severe anaphylactic reactions (grades III or IV). Conclusion There is an urgent need for a simpler symptom- or system-based classification and scoring system to create an awareness for HSRs to BSs. A better understanding of the pathophysiology of HSRs and increased clinical experience in the treatment of side effects will provide timely control of unexpected reactions. As a result, immunotherapy with BSs will become safer in the future.
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Ceschi A, Noseda R, Palin K, Verhamme K. Immune Checkpoint Inhibitor-Related Cytokine Release Syndrome: Analysis of WHO Global Pharmacovigilance Database. Front Pharmacol 2020; 11:557. [PMID: 32425791 PMCID: PMC7212758 DOI: 10.3389/fphar.2020.00557] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/14/2020] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have proven effective in the treatment of numerous cancers; however, they have been associated with immune-related adverse events (irAEs), among which cytokine release syndrome (CRS) has been reported in a few case reports. To describe the burden of ICI-related CRS and raise awareness of CRS as irAE, we queried VigiBase, the World Health Organization global database of spontaneously reported suspected adverse drug reactions (ADRs), and retrieved safety reports of suspected CRS associated with ICIs, gathered in the database through January 12th 2020. We assessed ICI-related CRS safety reports in terms of geographical and temporal patterns of reporting, patient demographics and clinical features, treatment characteristics, CRS clinical presentation, timing, seriousness, and outcome. We retrieved 58 cases of whom 43 (74%) reported CRS with anti-programmed death-1/anti-programmed death-ligand 1 agents. Melanoma (n=17, 29%) and hematologic malignancies (n=16, 28%) were the most common underlying cancers. ICIs were the solely suspected drugs in 37 (64%) cases. Typical signs and symptoms of CRS were reported in 25 (43%) patients. ICI-related CRS developed a median of 4 weeks after ICI initiation (IQR 1–18 weeks, n=9, 16%). Besides two fatal cases, CRS recovered/was recovering at the time of reporting in 35 (60%) cases. We observed differences in the geographical pattern of ICI-related CRS reporting, with a high proportion of ICI-related CRS cases in Australia and North America (0.14 and 0.10% respectively). Due to ICI expanding indications, clinicians should be aware that ICIs could contribute to CRS onset in cancer patients as pharmacological triggers.
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Affiliation(s)
- Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.,Faculty of Biomedical Sciences, University of Southern Switzerland, Lugano, Switzerland
| | - Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Karine Palin
- Université de Bordeaux, Collège Santé, Bordeaux, France
| | - Katia Verhamme
- Department of Medical Informatics, EMC Rotterdam, Rotterdam, Netherlands
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Ohira J, Kawamoto M, Sugino Y, Kohara N. A case report of fulminant cytokine release syndrome complicated by dermatomyositis after the combination therapy with immune checkpoint inhibitors. Medicine (Baltimore) 2020; 99:e19741. [PMID: 32282733 PMCID: PMC7220092 DOI: 10.1097/md.0000000000019741] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Immune-related adverse events (ir-AEs) are increasingly becoming a concern, as immune checkpoint inhibitors (ICIs) are used more frequently. Herein, we present a case of fulminant cytokine release syndrome (CRS) complicated by dermatomyositis after the combination therapy with ICIs. PATIENT CONCERNS A 70-year-old male developed dermatomyositis during the course of treatment with two ICIs, nivolumab and ipilimumab. He was treated by steroid pulse therapy, but the effect was limited. Afterwards, he had acute-onset high fever, hypotension, respiratory failure, impaired consciousness, renal failure, and coagulation abnormality at the same time. C reactive protein (CRP), creatinine kinase (CK), D-dimer, and ferritin levels were considerably elevated: CRP, 24 mg/dL; CK, 40,500 U/L; D-dimer, 290 μg/mL; ferritin, 329,000 ng/mL. DIAGNOSIS CRS induced by ICI combination therapy. INTERVENTIONS Given that high fever and elevated CRP level indicated potential sepsis, an antibiotic was used until the confirmation of negative blood cultures. All the simultaneous acute symptoms were supposed to be CRS. He was admitted to the intensive care unit (ICU), and temporary intubation and hemodialysis were needed. Immunosuppressive therapy was reinforced by mycophenolate mofetil together with steroid, and plasma exchange was performed for the elimination of abnormal proteins. OUTCOMES The patient's clinical symptoms and laboratory parameters gradually improved and he was discharged from the ICU in a month. CONCLUSION Fulminant CRS can be induced by ICI combination therapy. As the initial symptoms of CRS resemble sepsis, it is important to consider CRS as a differential diagnosis and to initiate immunosuppressive therapy early when needed. In steroid-resistant cases, early introduction of other immunosuppressive therapy and plasma exchange can be effective.
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Affiliation(s)
- Junichiro Ohira
- Department of Neurology, Kobe City Medical Center General Hospital, 650-0047, 2-1-1 Minatojima-Minamimachi, Chuou-ku, Kobe, Hyogo
- Department of Neurology, Kyoto University Hospital, 606-8507, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto
| | - Michi Kawamoto
- Department of Neurology, Kobe City Medical Center General Hospital, 650-0047, 2-1-1 Minatojima-Minamimachi, Chuou-ku, Kobe, Hyogo
| | - Yoshio Sugino
- Department of Urology, Kobe City Medical Center General Hospital, 650-0047, 2-1-1 Minatojima-Minamimachi, Chuou-ku, Kobe, Hyogo, Japan
| | - Nobuo Kohara
- Department of Neurology, Kobe City Medical Center General Hospital, 650-0047, 2-1-1 Minatojima-Minamimachi, Chuou-ku, Kobe, Hyogo
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Onoyama T, Takeda Y, Yamashita T, Hamamoto W, Sakamoto Y, Koda H, Kawata S, Matsumoto K, Isomoto H. Programmed cell death-1 inhibitor-related sclerosing cholangitis: A systematic review. World J Gastroenterol 2020; 26:353-365. [PMID: 31988594 PMCID: PMC6969883 DOI: 10.3748/wjg.v26.i3.353] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/07/2020] [Accepted: 01/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Programmed cell death-1 (PD-1) inhibitor has been indicated for many types of malignancies. However, these inhibitors also cause immune-related adverse events. Hepatobiliary disorder is a phenotype of immune-related adverse event affecting 0%–4.5% of patients treated with PD-1 inhibitors. Recent studies have reported PD-1 inhibitor-related sclerosing cholangitis (SC); however, the associated clinical and pathological features are unclear.
AIM To evaluate the clinical and pathological features of PD-1 inhibitor-related SC through a systematic review of the literature.
METHODS The review, conducted using electronic databases in PubMed, was restricted to the period from January 2014 to September 2019 and focused on case reports/series on PD-1 inhibitor-related SC published in English. We scanned the references of the selected literature to identify any further relevant studies. Six cases previously studied by us, including three that have not yet been published, were included in this review.
RESULTS Thirty-one PD-1 inhibitor-related SC cases were evaluated. Median age of patients was 67 years (range, 43–89), with a male to female ratio of 21:10. The main disease requiring PD-1 inhibitor treatment was non-small cell lung cancer. Agents that caused PD-1 inhibitor-related SC were nivolumab (19 cases), pembrolizumab (10 cases), avelumab (1 case), and durvalumab (1 case). The median number of cycles until PD-1 inhibitor-related SC onset was 5.5 (range, 1–27). Abdominal pain or discomfort (35.5%, 11/31) was the most frequent symptom. Blood serum tests identified liver dysfunction with a notable increase in biliary tract enzymes relative to hepatic enzymes, and a normal level of serum immunoglobulin G4. Biliary dilation without obstruction (76.9%, 20/26), diffuse hypertrophy of the extrahepatic biliary tract (90.5%, 19/21), and multiple strictures of the intrahepatic biliary tract (30.4%, 7/23) were noted. In 11/23 (47.8%) cases, pathological examination indicated that CD8+ T cells were the dominant inflammatory cells in the bile duct or peribiliary tract. Although corticosteroids were mainly used for PD inhibitor-related SC treatment, the response rate was 11.5% (3/26).
CONCLUSION Some clinical and pathological features of PD-1 inhibitor-related SC were revealed. To establish diagnostic criteria for PD-1 inhibitor-related SC, more cases need to be evaluated.
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Affiliation(s)
- Takumi Onoyama
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Yohei Takeda
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Taro Yamashita
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Wataru Hamamoto
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Yuri Sakamoto
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Hiroki Koda
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Soichiro Kawata
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Kazuya Matsumoto
- Internal Medicine, Irisawa Medical Clinic, Shimane prefecture 690-0025, Japan
| | - Hajime Isomoto
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
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Honjo O, Kubo T, Sugaya F, Nishizaka T, Kato K, Hirohashi Y, Takahashi H, Torigoe T. Severe cytokine release syndrome resulting in purpura fulminans despite successful response to nivolumab therapy in a patient with pleomorphic carcinoma of the lung: a case report. J Immunother Cancer 2019; 7:97. [PMID: 30944043 PMCID: PMC6448268 DOI: 10.1186/s40425-019-0582-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/28/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have provided more options in the treatment of lung cancer. However, ICIs can cause several unfavorable reactions generally referred to as immune-related adverse effects. CASE PRESENTATION In this report, we present the case of a 52-year-old woman with successful regression of pleomorphic carcinoma of the lung following nivolumab therapy. She developed purpura fulminans (PF) ultimately resulting in amputation of both lower extremities. Blood tests revealed thrombocytopenia with increased serum soluble IL-2 receptor, ferritin, and triglyceride levels suggesting hemophagocytic lymphohistiocytosis (HLH). In addition, serum A disintegrin-like and metalloproteinase with thrombospondin type 1 motifs 13 activity was decreased, suggesting thrombotic thrombocytopenic purpura (TTP). Further detailed analysis revealed severe hypercytokinemia including increased levels of IL-1β, IL-6, IL-10, TNFα, IFNγ, and G-CSF. CONCLUSION The severe systemic inflammatory reaction and impaired peripheral circulation in this patient was attributed to excessive immunological effect induced by nivolumab resulting in cytokine release syndrome (CRS). This is the first report of a patient with multiple pathological conditions including HLH, TTP-like condition, and PF presumably arising from ICI-induced CRS. Further accumulating thoroughly investigated cases would lead to better understanding of the disease and development of reliable cancer immunotherapy.
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Affiliation(s)
- Osamu Honjo
- Department of Respiratory Medicine, Sapporo Minami-Sanjo Hospital, Sapporo, Hokkaido, 060-0063, Japan
| | - Terufumi Kubo
- Department of Pathology, Sapporo Medical University, School of Medicine, South 1, West 17, Chuo-ku, Sapporo, Hokkaido, 060-8556, Japan.
| | - Fumiko Sugaya
- Department of Respiratory Medicine, Teine Keijinkai Hospital, Sapporo, Hokkaido, 006-8555, Japan
| | | | - Koji Kato
- Department of Pathology, Sapporo Medical University, School of Medicine, South 1, West 17, Chuo-ku, Sapporo, Hokkaido, 060-8556, Japan
- Department of Respiratory Medicine and Allergology, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, 060-8543, Japan
| | - Yoshihiko Hirohashi
- Department of Pathology, Sapporo Medical University, School of Medicine, South 1, West 17, Chuo-ku, Sapporo, Hokkaido, 060-8556, Japan
| | - Hiroki Takahashi
- Department of Respiratory Medicine and Allergology, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, 060-8543, Japan
| | - Toshihiko Torigoe
- Department of Pathology, Sapporo Medical University, School of Medicine, South 1, West 17, Chuo-ku, Sapporo, Hokkaido, 060-8556, Japan
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