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Basek A, Jakubiak GK, Cieślar G, Stanek A. Life-Threatening Endocrinological Immune-Related Adverse Events of Immune Checkpoint Inhibitor Therapy. Cancers (Basel) 2023; 15:5786. [PMID: 38136332 PMCID: PMC10742092 DOI: 10.3390/cancers15245786] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/29/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Malignant neoplasms are currently one of the leading causes of morbidity and mortality worldwide, posing a major public health challenge. However, recent advances in research in cancer biology and immunity have led to the development of immunotherapy, which is now used on an everyday basis in cancer treatment in addition to surgical treatment, classical cytostatics, and radiotherapy. The efficacy of immunotherapy has promoted the great popularity of this treatment among patients, as well as significant research interest. The increasing number of patients being treated with immunotherapy not only reassures physicians of the efficacy of this technique but also shows the wide spectrum of side effects of this therapy, which has not been considered before. Immune-related adverse events may affect many systems and organs, such as digestive, cardiovascular, respiratory, skin, or endocrine organs. Most complications have a mild or moderate course, but there are life-threatening manifestations that are essential to be aware of because if they are not properly diagnosed and treated on time, they can have fatal consequences. The purpose of this paper was to present the results of a literature review on the current state of knowledge on life-threatening endocrine side effects (such as adrenal crisis, thyroid storm, myxoedema crisis, diabetic ketoacidosis, and severe hypocalcaemia) of immune checkpoint inhibitors to provide information on symptoms, diagnostics, and management strategies.
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Affiliation(s)
- Aleksandra Basek
- Student Research Group, Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland;
| | - Grzegorz K. Jakubiak
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
| | - Grzegorz Cieślar
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
| | - Agata Stanek
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
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Ramburuth V, Rajkanna J. Thyroid Storm and Type 1 Diabetes Mellitus Induced by Combined Ipilimumab and Nivolumab Immunotherapy: A Case Report. Cureus 2023; 15:e46985. [PMID: 38022251 PMCID: PMC10640894 DOI: 10.7759/cureus.46985] [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: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Immune checkpoint inhibitors have revolutionised the management of cancer, and they are being used in combination to improve survival outcomes. Combination therapy is, however, associated with an increase in the frequency and severity of immune-related adverse events such as endocrine disorders. We report a case of simultaneous onset thyroid storm and type 1 diabetes mellitus induced by ipilimumab and nivolumab therapy in a patient with advanced melanoma. This case report suggests that combination immunotherapy can trigger a robust immune reaction leading to the development of multiple life-threatening endocrinopathies, including rapid onset destructive thyroiditis and insulitis. Prompt identification and management are essential to prevent morbidity and mortality.
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Affiliation(s)
- Vivek Ramburuth
- Internal Medicine, Peterborough City Hospital, Peterborough, GBR
| | - Jeyanthy Rajkanna
- Endocrinology and Diabetes, Peterborough City Hospital, Peterborough, GBR
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Elmenyar E, Aoun S, Al Saadi Z, Barkumi A, Cander B, Al-Thani H, El-Menyar A. Data Analysis and Systematic Scoping Review on the Pathogenesis and Modalities of Treatment of Thyroid Storm Complicated with Myocardial Involvement and Shock. Diagnostics (Basel) 2023; 13:3028. [PMID: 37835772 PMCID: PMC10572182 DOI: 10.3390/diagnostics13193028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Thyroid storm (TS) is a rare and fatal endocrine emergency that occurs due to undiagnosed and inadequately treated hyperthyroidism after stressful conditions in patients with thyroid disorders. The objective of this systematic scoping review was to better understand the pathophysiology of TS and its complications, in terms of myocardial affection, tachyarrhythmia, and cardiogenic shock. In addition, we explored the pharmacological, mechanical, and surgical treatments for TS. We also evaluated the outcomes of TS according to sex and cardiac involvement. Additionally, analytical analysis was performed on the selected data. A literature review of peer-reviewed journals was carried out thoroughly using medical terms, MeSH on PubMed, Google Scholar, and combinations such as thyrotoxicosis-induced cardiomyopathy, thyroid storm, cardiogenic shock, myocardial infarction, endocrine emergency, Burch-Wartofsky score, extracorporeal circulatory support, and thyroidectomy. A total of 231 papers were eligible (2 retrospective studies, 5 case series, and 224 case reports) with a total of 256 TS patients with cardiac involvement between April 2003 and August 2023. All age groups, sexes, patients with TS-induced cardiomyopathy, non-atherosclerotic myocardial infarction, tachyarrhythmia, heart failure, shock, and different forms of treatment were discussed. Non-English language articles, cases without cardiac involvement, and cases in which treatment modalities were not specified were excluded. Female sex was predominant, with 154 female and 102 male patients. Approximately 82% of patients received beta-blockers (BBs), 16.3% were placed on extracorporeal membrane oxygenation (ECMO) support, 16.3% received therapeutic plasma exchange (TPE), and 13.8% underwent continuous renal replacement therapy (CRRT), continuous venovenous hemofiltration (CVVHD), or dialysis. Overall, 18 females and 16 males died. BB-induced circulatory collapse, acute renal failure, CRRT, and ventricular fibrillation were significantly associated with mortality. Awareness of TS and not only thyrotoxicosis is vital for timely and appropriate treatment. The early diagnosis and management of TS in cardiac settings, including pharmacological, mechanical, and surgical modalities, can save high-risk patients. Sex matters in the presentation, treatment, and mortality of this population. However, further large-scale, and well-designed studies are required.
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Affiliation(s)
- Eman Elmenyar
- Faculty of Medicine, Internship, Bahcesehir University, Istanbul 34734, Turkey; (E.E.); (S.A.); (Z.A.S.); (A.B.)
| | - Sarah Aoun
- Faculty of Medicine, Internship, Bahcesehir University, Istanbul 34734, Turkey; (E.E.); (S.A.); (Z.A.S.); (A.B.)
| | - Zain Al Saadi
- Faculty of Medicine, Internship, Bahcesehir University, Istanbul 34734, Turkey; (E.E.); (S.A.); (Z.A.S.); (A.B.)
| | - Ahmed Barkumi
- Faculty of Medicine, Internship, Bahcesehir University, Istanbul 34734, Turkey; (E.E.); (S.A.); (Z.A.S.); (A.B.)
| | - Basar Cander
- Department of Emergency Medicine, Kanuni Sultan Süleyman Training & Research Hospital, Istanbul 34303, Turkey;
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha 3050, Qatar;
| | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad General Hospital, Doha 3050, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha 24144, Qatar
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Profili NI, Castelli R, Gidaro A, Merella A, Manetti R, Palmieri G, Maioli M, Delitala AP. Endocrine Side Effects in Patients Treated with Immune Checkpoint Inhibitors: A Narrative Review. J Clin Med 2023; 12:5161. [PMID: 37568563 PMCID: PMC10419837 DOI: 10.3390/jcm12155161] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/19/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023] Open
Abstract
Checkpoint inhibitors are monoclonal antibodies that elicit an anti-tumor response by stimulating immune system. Their use has improved the treatment of different types of cancer such as melanoma, breast carcinoma, lung, stomach, colon, liver, renal cell carcinoma, and Hodgkin's lymphoma, but several adverse events have been reported. Although the etiology of these effects is not completely understood, an uncontrolled activation of the immune system has been postulated. Indeed, some studies showed a cross reactivity of T cells, which acted against tumor antigens as well as antigens in the tissues of patients who developed immune-related adverse events. Despite the known possibility of developing immune-related adverse events, early diagnosis, monitoring during therapy, and treatment are fundamental for the best supportive care and administration of immune checkpoint inhibitors. The aim of this review is to guide the clinician in early diagnosis, management, and treatment of the endocrinological adverse effects in the major endocrine glands (thyroid, pituitary, adrenal, endocrine pancreas, and parathyroid).
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Affiliation(s)
- Nicia I. Profili
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Roberto Castelli
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Alessandro Merella
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Roberto Manetti
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Giuseppe Palmieri
- Department of Biochemical Science, University of Sassari, 07100 Sassari, Italy
| | - Margherita Maioli
- Department of Biochemical Science, University of Sassari, 07100 Sassari, Italy
| | - Alessandro P. Delitala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
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Baraka B, Abosheaishaa H, Nassar M. Immunotherapy-induced thyroid dysfunction: an updated review. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2023; 35:48. [DOI: 10.1186/s43162-023-00210-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/28/2023] [Indexed: 10/24/2023] Open
Abstract
Abstract
Immunotherapy medicines (immune checkpoint inhibitors, ICIs) that work directly on the immune system have shown vastly increased survival for people with cancer in phases 2 and 3 clinical studies during the past few years. Nevertheless, ICI treatment (irAEs) may trigger immune-related adverse effects. An underactive thyroid is among the most frequent endocrine irAE, affecting about 40% of individuals who received ICIs. Our review aims to collect and organize the most recent data on immunotherapy-induced thyroid dysfunction in cancer patients, including its prevalence, diagnostic criteria, and treatment options and to summarize those findings in a comprehensive review article. The incidence of irAEs varies depending on the type of cancer and the treatment regimen. Thyroid ultrasound, radioactive uptake scan, and PET CT scan can aid in diagnosing thyroid dysfunction. Thyroid dysfunction treatment necessitates collaboration between specialists in oncology, endocrinology, and primary care in a multidisciplinary team discussion. The prognosis of patients who suffered from thyroid dysfunction while on ICIs treatment is reasonably good. Suboptimal baseline thyroid function was linked with decreased overall survival (OS) among ICI-treated patients, but initiating replacement hormonal therapy after ICI initiation was associated with enhanced OS. More research work is required to identify these links and mechanisms of action.
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Cardona Z, Sosman JA, Chandra S, Huang W. Endocrine side effects of immune checkpoint inhibitors. Front Endocrinol (Lausanne) 2023; 14:1157805. [PMID: 37251665 PMCID: PMC10210589 DOI: 10.3389/fendo.2023.1157805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/05/2023] [Indexed: 05/31/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have increasingly been the mainstay of treatment for numerous malignancies. However, due to their association with autoimmunity, ICIs have resulted in a variety of side effects that involve multiple organs including the endocrine system. In this review article, we describe our current understanding of the autoimmune endocrinopathies as a result of the use of ICIs. We will review the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of the most commonly encountered endocrinopathies, including thyroiditis, hypophysitis, Type 1 diabetes, adrenalitis, and central diabetes insipidus.
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Affiliation(s)
- Zulma Cardona
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jeffrey A. Sosman
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sunandana Chandra
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Wenyu Huang
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Hayakawa G, Leibowitz MM, Datta S, Oyibo SO. Transient Thyroiditis Followed by Exacerbation of Hypothyroidism After Immune Checkpoint Inhibitor Therapy (Nivolumab and Ipilimumab) in a Patient With Pre-existing Autoimmune Hypothyroidism: A Case Report. Cureus 2023; 15:e39439. [PMID: 37234452 PMCID: PMC10208279 DOI: 10.7759/cureus.39439] [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: 05/24/2023] [Indexed: 05/28/2023] Open
Abstract
Treatment with immune checkpoint inhibitors has improved the prognosis of solid tumors. However, immune-related adverse events (IRAEs), including exacerbation of pre-existing autoimmune disease, are common and have become more frequent with combination therapy. The literature is scanty regarding reports of the use of combination immune checkpoint therapy in patients with pre-existing autoimmune hypothyroidism. We report a case of a man with a history of hypothyroidism, who developed transient thyroiditis, characterized by a thyrotoxic phase followed by a severe hypothyroid phase soon after receiving combination therapy (nivolumab and ipilimumab) for the treatment of a malignant pleural mesothelioma. He had been on a stable low dose of levothyroxine for 12 years prior to this episode. His levothyroxine requirement markedly increased soon after the episode of immune checkpoint inhibitor-induced thyroiditis. Immune checkpoint inhibitors can cause destructive thyroiditis followed by exacerbation of hypothyroidism in patients with pre-existing autoimmune hypothyroidism, such that patients end up on a higher dose of levothyroxine. This case will add to the growing literature regarding thyroid IRAEs associated with the use of immune checkpoint inhibitors in patients with pre-existing autoimmune thyroid disease.
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Affiliation(s)
- Guy Hayakawa
- General Medicine, Peterborough City Hospital, Peterborough, GBR
| | | | - Sudipta Datta
- Oncology, Peterborough City Hospital, Peterborough, GBR
| | - Samson O Oyibo
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
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Abstract
Immune-related adverse events (irAEs) are caused by immune checkpoint inhibitors in several organs including the endocrine glands. Thyroid dysfunction (thyroid irAEs) is often observed among endocrine irAEs and is induced by blockade of programmed cell death 1 (PD-1), programmed death ligand 1, or PD-1 plus cytotoxic T-lymphocyte antigen 4. Endocrinologically, destructive thyroiditis or hypothyroidism is observed in most cases, whereas hyperthyroidism (Graves' disease) is rare. Most patients who develop destructive thyroiditis or hypothyroidism subsequently require thyroid hormone replacement therapy. Thyroid irAE development is associated with prolonged survival in patients with non-small cell lung carcinoma. The incidence of thyroid irAEs is higher in patients who are positive versus negative for anti-thyroid antibodies at baseline, suggesting that these antibodies can predict thyroid irAE development. Cytotoxic T cells, especially CD4 T cells, are reportedly involved in the development of destructive thyroiditis. In this review, we describe the clinical features, potential biomarkers, and mechanism of thyroid irAEs.
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Affiliation(s)
- Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Japan.
| | - Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Japan
| | - Yoshinori Yasuda
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Fidilio E, Navarro-González E, Romero-Lluch AR, Iglesias P, Diez Gómez JJ, Anda Apiñániz E, Santos Mazo E, Zafón C. Thyroid disorders associated with immune control point inhibitors. ENDOCRINOL DIAB NUTR 2021; 68:408-415. [PMID: 34742474 DOI: 10.1016/j.endien.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/25/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICPI) have improved progression-free survival in several solid tumors. Side effects are related to overstimulation of the immune system. Thyroid dysfunction (TD) is the most common endocrine immune-related adverse event of ICPI. OBJECTIVE To describe the clinical presentation and the course of TD in cancer patients treated with ICPI referred to an endocrinology outpatient clinic. MATERIAL AND METHODS This was a descriptive, retrospective and multicenter study of patients with TD associated with ICPI in six Spanish hospitals. RESULTS 120 patients (50.8% women), mean age 60 ± 12 years were included. The initial TD was hypothyroidism in 49% of patients and hyperthyroidism in 51%, with an average of 76 (41-140) and 43 (26-82) days respectively between the onset of ICPI and the analytical alteration. Significantly, the earlier the first analytical determination was, the greater the prevalence of hyperthyroidism. A turnover was observed in 80% of subjects during follow-up, mostly from hyperthyroidism to hypothyroidism. Twenty-one percent received double ICPI therapy. The most frequent form of presentation in monotherapy was hypothyroidism (57%), and in double therapy it was hyperthyroidism (77%) (p = 0.002). Patients under double therapy showed thyroid alterations earlier than those in the monotherapy group (p = 0.001). After a follow-up of 205 (112-360) days, half of the patients continued under levothyroxine treatment. CONCLUSIONS Hypothyroidism and hyperthyroidism present in a similar proportion in cancer patients undergoing ICPI therapy. Our results suggest that transitory hyperthyroidism may not be detected in a relevant number of cases. In addition, TD in double therapy presents earlier. This should be taken into account in the follow-up protocols of these patients.
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Affiliation(s)
- Enzamaria Fidilio
- Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
| | - Elena Navarro-González
- Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana R Romero-Lluch
- Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Pedro Iglesias
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain; Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Juan José Diez Gómez
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Emma Anda Apiñániz
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Estefanía Santos Mazo
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Burgos, Burgos, Spain
| | - Carles Zafón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Percik R, Liel Y, Urban D, Bar J, Ben-Ami E, Abu Tailakh M. Thyroid dysfunction and survival in cancer patients treated with immune checkpoint inhibitors: analyses from a large single tertiary cancer center database. Acta Oncol 2021; 60:1466-1471. [PMID: 34379562 DOI: 10.1080/0284186x.2021.1958006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE We aimed to assess the incidence, clinical and biochemical course of immunotherapy-induced thyroiditis and its implication on patients' survival, based on an extensive clinical experience from a tertiary cancer center. METHODS Analyses were based on data from the electronic medical records of cancer patients treated with CPIs. Data included demographic characteristics, cancer type, Thyroid function tests (TFT), and survival. RESULTS Thyroid function tests were available for 934 patients. After excluding patients with impaired baseline TFT or levothyroxine treatment, 754 euthyroid patients were included in the core analyses. Of those, 301 (39.9%) patients developed thyroid dysfunction ('thyroiditis'). Thyroiditis was more prevalent in patients with renal cell carcinoma than other types of cancer. Survival rates were comparable in patients who developed thyroiditis and in those who did not. during the 5 years follow-up period, there was a non-significant trend toward improved survival in patients who developed TD in four predefined groups: melanoma, lung cancer, renal cell carcinoma, and transitional cell carcinoma. Nevertheless, we observed a highly significant survival benefit for patients with renal cell carcinoma who developed TD (HR = 0.19, 95% CI 0.06-0.60; p = 0.005). CONCLUSIONS Thyroiditis is common, often asymptomatic, and is more prevalent in patients treated with combinations of nivolumab and PD-L1 inhibitors, and in patients with renal cell carcinoma. Thyroiditis was associated with a trend for a survival benefit, particularly in patients with renal cell carcinoma.
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Affiliation(s)
- Ruth Percik
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Institute of Oncology, Endo-Oncology Clinic, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Liel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Damien Urban
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Jair Bar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Eytan Ben-Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Muhammad Abu Tailakh
- Department of Nursing, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Soroka University Medical Center, Beer-Sheva, Israel
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11
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Deligiorgi MV, Sagredou S, Vakkas L, Trafalis DT. The Continuum of Thyroid Disorders Related to Immune Checkpoint Inhibitors: Still Many Pending Queries. Cancers (Basel) 2021; 13:5277. [PMID: 34771441 PMCID: PMC8582503 DOI: 10.3390/cancers13215277] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Until more data are available to shed light on the thyroid disorders related to immune checkpoint inhibitors (ICPi) implemented for the treatment of hematological malignancies, the decision-making is guided by pertinent data derived mostly from solid tumors. METHODS The present review provides a comprehensive and updated overview of the thyroid disorders related to ICPi, namely to inhibitors of cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death (PD) 1 (PD-1), and the ligand of the latter (PD-L1). RESULTS With the increasing recognition of ir thyroid disorders, many outstanding issues have emerged. Ir thyroid disorders are reminiscent of, but not identical to, thyroid autoimmunity. Interclass and intraclass ICPi differences regarding thyroid immunotoxicity await interpretation. The available data concerning the predictive value of thyroid autoantibodies for the development of ir thyroid disorders are inconclusive. Mounting data indicate an association of ir thyroid disorders with ICPi efficacy, but a causative link is still lacking. The path forward is a tailored approach, entailing: (i) the validation of tumor-specific, patient-specific, and ICPi-specific predictive factors; (ii) appropriate patient selection; (iii) the uncoupling of antitumor immunity from immunotoxicity; (iv) a multidisciplinary initiative; and (v) global registry strategies. CONCLUSIONS Untangling and harnessing the interrelationship of immuno-oncology with endocrinology underlying the ir thyroid disorders will yield the optimal patient care.
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Affiliation(s)
- Maria V. Deligiorgi
- Department of Pharmacology—Clinical Pharmacology Unit, Faculty of Medicine, National and Kapodistrian University of Athens, Building 16, 1st Floor, 75 Mikras Asias Str., Goudi, 11527 Athens, Greece; (S.S.); (L.V.); (D.T.T.)
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12
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Hagiwara R, Suzuki D, Tonezawa S, Saikawa R, Funazaki S, Yoshida M, Washino S, Miyagawa T, Hara K, Yamada H. Spontaneous recovery of immune checkpoint inhibitor-induced thyroiditis with high free T4 level: A case report. Clin Case Rep 2021; 9:e04781. [PMID: 34512984 PMCID: PMC8423082 DOI: 10.1002/ccr3.4781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/09/2021] [Accepted: 08/22/2021] [Indexed: 12/19/2022] Open
Abstract
We describe a case of severe hyperthyroidism with high free thyroxine and C-reactive protein levels, wherein thyroid function rapidly improved without treatment. In a similar case, conservative management with imaging follow-up can be considered.
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Affiliation(s)
- Rie Hagiwara
- Department of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Daisuke Suzuki
- Department of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Shiori Tonezawa
- Department of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Rika Saikawa
- Department of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Shunsuke Funazaki
- Department of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Masashi Yoshida
- Department of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Satoshi Washino
- Department of UrologyJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Tomoaki Miyagawa
- Department of UrologyJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Kazuo Hara
- Department of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Hodaka Yamada
- Department of Endocrinology and MetabolismJichi Medical University Saitama Medical CenterSaitamaJapan
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Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target two key signalling pathways related to T cell activation and exhaustion, by binding to and inhibiting cytotoxic T lymphocyte antigen 4 (CTLA4) or PD1 and its ligand PDL1. ICIs, such as nivolumab, pembrolizumab and ipilimumab, are approved for the treatment of numerous and diverse cancer types, in various combination regimens, and are now an established cornerstone of cancer therapeutics. Toxicities induced by ICIs are autoimmune in nature and are referred to as immune-related adverse events (irAEs); these events can affect any organ system in an unpredictable fashion. Importantly, irAEs can manifest as endocrinopathies involving the thyroid (hypothyroidism or thyrotoxicosis), pituitary (hypophysitis), adrenal glands (adrenal insufficiency) and pancreas (diabetes mellitus). These events are a frequent source of acute and persistent morbidity in patients treated with ICIs and can even be fatal. Over the past few years, there has been a growing understanding of the underlying pathogenesis of irAEs that has led to the development of more effective management strategies. Herein, we review the current understanding of the pathobiology, clinical manifestations and treatment approaches to endocrine toxicities arising from ICIs.
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Affiliation(s)
- Jordan J Wright
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Alvin C Powers
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA.
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14
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Alteraciones tiroideas asociadas con los inhibidores de los puntos de control inmunitario. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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15
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Zhan L, Feng HF, Liu HQ, Guo LT, Chen C, Yao XL, Sun SR. Immune Checkpoint Inhibitors-Related Thyroid Dysfunction: Epidemiology, Clinical Presentation, Possible Pathogenesis, and Management. Front Endocrinol (Lausanne) 2021; 12:649863. [PMID: 34177799 PMCID: PMC8224170 DOI: 10.3389/fendo.2021.649863] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/31/2021] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a group of drugs employed in the treatment of various types of malignant tumors and improve the therapeutic effect. ICIs blocks negative co-stimulatory molecules, such as programmed cell death gene-1 (PD-1) and its ligand (PD-L1) and cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), reactivating the recognition and killing effect of the immune system on tumors. However, the reactivation of the immune system can also lead to the death of normal organs, tissues, and cells, eventually leading to immune-related adverse events (IRAEs). IRAEs involve various organs and tissues and also cause thyroid dysfunction. This article reviews the epidemiology, clinical manifestations, possible pathogenesis, and management of ICIs-related thyroid dysfunction.
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Affiliation(s)
- Ling Zhan
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hong-fang Feng
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China
- Department of Breast Surgery, Thyroid Surgery, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Edong Healthcare Group, Huangshi, China
| | - Han-qing Liu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lian-tao Guo
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiao-li Yao
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China
- *Correspondence: Xiao-li Yao, ; Sheng-rong Sun,
| | - Sheng-rong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China
- *Correspondence: Xiao-li Yao, ; Sheng-rong Sun,
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16
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Muir CA, Menzies AM, Clifton-Bligh R, Tsang VHM. Thyroid Toxicity Following Immune Checkpoint Inhibitor Treatment in Advanced Cancer. Thyroid 2020; 30:1458-1469. [PMID: 32264785 DOI: 10.1089/thy.2020.0032] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: Inhibitory antibodies against cytotoxic T lymphocyte antigen-4 (CTLA-4) and programmed cell death-1 (PD-1) have antitumor efficacy and are now standard of care in the management of multiple cancer subtypes. However, the use is complicated by the development of autoimmunity, which can occur in multiple organ systems. Thyroiditis is the most common immune-related adverse event. Summary: Immune checkpoint inhibitor (ICI)-associated thyroiditis affects over 10% of treated patients. PD-1 inhibitors are associated with greater risk of thyroid dysfunction relative to CTLA-4 inhibitors, although the highest risk occurs with combined anti-CTLA-4 and anti-PD-1 treatment. Onset is typically rapid, within weeks to months and both hyperthyroidism and hypothyroidism can occur. The most frequent pattern of thyroid dysfunction is transient hyperthyroidism with evolution to hypothyroidism over four to six weeks. Most cases are asymptomatic and resolve without dedicated treatment. There is no sex or age predominance, and predictive risk factors have not been reliably identified. Thyroid autoantibodies are variably present and are not clearly related to the risk or progression of thyroid dysfunction following treatment with an ICI. Observational data suggest that development of ICI-associated thyroiditis may predict improved survival. Conclusions: ICI-associated thyroiditis is a distinct clinical entity. Mechanisms underlying etiology remain largely unknown. Awareness among health professionals is important to limit morbidity and avoid unnecessary periods of untreated hypothyroidism.
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Affiliation(s)
- Christopher A Muir
- Nothern Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, St. Leonards, Australia
| | - Alexander M Menzies
- Nothern Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Melanoma Medical Oncology, Melanoma Institute Australia, Wollstonecraft, Australia
- Department of Medical Oncology and Royal North Shore Hospital, St. Leonards, Australia
| | - Roderick Clifton-Bligh
- Nothern Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, St. Leonards, Australia
- Department of Endocrinology, Royal North Shore Hospital, St. Leonards, Australia
| | - Venessa H M Tsang
- Nothern Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Cancer Genetics Laboratory, Kolling Institute of Medical Research, St. Leonards, Australia
- Department of Endocrinology, Royal North Shore Hospital, St. Leonards, Australia
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17
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Coureau M, Meert AP, Berghmans T, Grigoriu B. Efficacy and Toxicity of Immune -Checkpoint Inhibitors in Patients With Preexisting Autoimmune Disorders. Front Med (Lausanne) 2020; 7:137. [PMID: 32457912 PMCID: PMC7220995 DOI: 10.3389/fmed.2020.00137] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022] Open
Abstract
Immunotherapy is an important armamentarium for cancer treatment nowadays. Apart from their significant effectiveness in controlling disease they also generate potential severe immune related adverse effects. Preexistence of immune related conditions may eventually predispose to the development of more severe complication and extreme caution have been taken in treating these patients. We performed a literature review searching for case reports and case series in order to offer evidence-based data for clinical management of these patients. Preexisting serological-only immune abnormalities or presence of a predisposing genetic background does not seem to confer significant risk but existing data is scarce. Most patients with preexistent autoimmune diseases can probably treated with checkpoint inhibitors as they seem to have at least the same response rate as the general cancer population. Under treatment, a significant part of them (at least 30%) can experience a flare of their baseline disease which can sometime be severe. Life-threatening cases seems rare and disease flare can be generally managed with steroids. The volume of available data is more important for rheumatologic diseases than for inflammatory bowel diseases were more caution should be observed. However, it has to be kept in mind that new immune related adverse effects (IrAE) are seen with a similar frequency as the flare of the baseline disease. Both flare-up's and newly developed IrAE are generally manageable with a careful clinical follow-up and prompt therapy.
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Affiliation(s)
- Michelle Coureau
- Service des Soins Intensifs et Urgences Oncologiques, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Anne-Pascale Meert
- Service des Soins Intensifs et Urgences Oncologiques, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Thierry Berghmans
- Service d'Oncologie Medicale, Unité d'Oncologie Thoracique, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Bogdan Grigoriu
- Service des Soins Intensifs et Urgences Oncologiques, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
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18
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Li W, Wang H, Chen B, Zhao S, Zhang X, Jia K, Deng J, He Y, Zhou C. Anti PD-1 monoclonal antibody induced autoimmune diabetes mellitus: a case report and brief review. Transl Lung Cancer Res 2020; 9:379-388. [PMID: 32420079 PMCID: PMC7225154 DOI: 10.21037/tlcr.2020.03.05] [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] [Indexed: 01/10/2023]
Abstract
Nowadays, immune checkpoint inhibitor therapy has been used in more and more cancer patients. These agents were associated with immune-related adverse effects, and autoimmune diabetes mellitus is one of them. And it is not common but can be potentially fatal. Anti PD-1 monoclonal antibody is a humanized IgG4 antibody against PD-1, which has been applied in advanced non-small cell lung cancer (NSCLC) treatment. In this paper, we reported the case of autoimmune diabetes mellitus induced by anti PD-1 monoclonal antibody in NSCLC treatment. Here is a 73-year-old male patient with no diabetes history who had anti PD-1 monoclonal antibody 200 mg every 3 weeks for NSCLC treatment. After 10 cycles of the therapy, his blood glucose level elevated and he suffered diabetic ketoacidosis (DKA). And his C-peptide was significantly decreased with negative relative auto-antibodies. Combined with his medical history and the laboratory examination, anti PD-1 monoclonal antibody induced autoimmune diabetes mellitus was diagnosed. After recovering from DKA and controlling his blood glucose, his anti PD-1 therapy was continued and he still got some benefit. This report suggested that glycemic monitoring is imperative during this anti PD-1 monoclonal antibody treatment. Moreover, after controlling the blood glucose level, continuing the immune therapy could still be benefit and safe for the patient.
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Affiliation(s)
- Wei Li
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Hao Wang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Bin Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Sha Zhao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Xiaoshen Zhang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Keyi Jia
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Juan Deng
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Yayi He
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Caicun Zhou
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
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