1
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Kennedy LB, Salama AKS. Multiple Options: How to Choose Therapy in Frontline Metastatic Melanoma. Curr Oncol Rep 2024:10.1007/s11912-024-01547-0. [PMID: 38837107 DOI: 10.1007/s11912-024-01547-0] [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: 05/10/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE OF REVIEW Given the rapid development of multiple targeted and immune therapies for patients with advanced melanoma, it can be challenging to select a therapy based on currently available data. This review aims to provide an overview of frontline options for metastatic melanoma, with practical guidance for selecting a treatment regimen. RECENT FINDINGS Recently reported data from randomized trials suggests that the majority of patients with unresectable melanoma should receive a PD-1 checkpoint inhibitor as part of their first line therapy, irrespective of BRAF mutation status. Additional data also suggests that combination immunotherapies result in improved outcomes compared to single agent, albeit at the cost of increased toxicity, though to date no biomarker exists to help guide treatment selection. As the number therapeutic options continue to grow for patients with advanced melanoma, there is likely to be a continued focus on combination strategies. Defining the optimal treatment approach in order to maximize efficacy while minimizing toxicity remains an area of active investigation.
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Affiliation(s)
- Lucy Boyce Kennedy
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH, 44195, USA
| | - April K S Salama
- Division of Medical Oncology, Duke University Hospital, Durham, NC, 27710, USA.
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Lasagna A, Sacchi P. The ABC of Immune-Mediated Hepatitis during Immunotherapy in Patients with Cancer: From Pathogenesis to Multidisciplinary Management. Cancers (Basel) 2024; 16:795. [PMID: 38398187 PMCID: PMC10886483 DOI: 10.3390/cancers16040795] [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: 11/16/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Immune-mediated hepatotoxicity (IMH) is not-so-rare complication during treatment with immune checkpoint inhibitors (ICIs). This narrative review aims to report the current knowledge on hepatic immune-related adverse events (irAEs) during immunotherapy from pathogenesis to multidisciplinary management. The majority of cases of IMH are asymptomatic and only a few patients may have clinical conditions. The severity of IMH is usually stratified according to Common Terminology for Clinical Adverse Events (CTCAE) criteria, but these scores may overestimate the clinical severity of IMH compared to the Drug-Induced Liver Injury Network (DILIN) scale. The differential diagnosis of IMH is challenging because the elevated liver enzymes can be due to a number of etiologies such as viral infection, autoimmune and metabolic diseases, liver metastases, biliary diseases, and other drugs. The cornerstones of IMH management are represented by withholding or delaying ICI administration and starting immunosuppressive therapy. A multidisciplinary team, including oncologists, hepatologists, internists, and emergency medicine physicians, is essential for the management of IMH.
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Affiliation(s)
- Angioletta Lasagna
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Paolo Sacchi
- Division of Infectious Diseases I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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Tang L, Li Q, Chen L, Li X, Gu S, He W, Pan Q, Wang L, Sun J, Yi X, Li Y. IL-21 collaborates with anti-TIGIT to restore NK cell function in chronic HBV infection. J Med Virol 2023; 95:e29142. [PMID: 37815034 DOI: 10.1002/jmv.29142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 10/11/2023]
Abstract
Available therapies for chronic hepatitis B virus (HBV) infection are not satisfying, and interleukin-21 (IL-21) and checkpoint inhibitors are potential therapeutic options. However, the mechanism underlying IL-21 and checkpoint inhibitors in treating chronic HBV infection is unclear. To explore whether IL-21 and checkpoint inhibitors promote HBV clearance by modulating the function of natural killer (NK) cells, we measured the phenotypes and functions of NK cells in chronic HBV-infected patients and healthy controls on mRNA and protein levels. We found that chronic HBV infection disturbed the transcriptome of NK cells, including decreased expression of KLRK1, TIGIT, GZMA, PRF1, and increased expression of CD69. We also observed altered phenotypes and functions of NK cells in chronic HBV-infected patients, characterized by decreased NKG2D expression, increased TIGIT expression and impaired interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α) production. Furthermore, these alterations cannot be restored by telbivudine treatment but can be partially restored by IL-21 and anti-TIGIT stimulation. IL-21 upregulated the expression of activating receptor CD16, CD69, and NKG2D on NK cells, enhanced IFN-γ production, cytolysis, and proliferation of NK cells, while anti-TIGIT promoted IFN-γ production in CD56dim subset exclusively in chronic HBV infected patients. Additionally, IL-21 was indispensable for anti-TIGIT in HBsAg clearance in mice bearing HBV. It enhanced IFN-γ production in splenic NK cells rather than intrahepatic NK cells, indicating a brand-new mechanism of IL-21 in HBV clearance when combined with anti-TIGIT. Overall, our findings contribute to the design of immunotherapy through enhancing the antiviral efficacy of NK cells in chronic HBV infection.
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Affiliation(s)
- Libo Tang
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Quanrun Li
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Key Infectious Diseases Laboratory (Preparatory) of Yunnan Provincial Department of Education, Department of Infectious Diseases, School of Clinical Medicine, The First Affiliated Yunnan Provincial Clinical Medical Center (Branch) for Infectious Diseases, Hospital of Dali University, Dali University, Dali, Yunnan, China
| | - Liang Chen
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Infectious Diseases, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Xiaowei Li
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Shuqin Gu
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Weiying He
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingqing Pan
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Liping Wang
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianru Sun
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xuan Yi
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yongyin Li
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Yibirin M, Mustafayev K, Hosry J, Pundhir P, Klingen J, Yepez Guevara E, Granwehr BP, Kaseb A, Naing A, Patel S, Shah AY, Skoulidis F, Tawbi HA, Wang L, Miller E, Zhang HC, Zurita-Saavedra A, Torres HA. Immune Checkpoint Inhibitors Suppress Hepatitis C Virus Replication in Infected Patients With Solid Tumors. Am J Gastroenterol 2023; 118:1609-1617. [PMID: 37307533 DOI: 10.14309/ajg.0000000000002361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/27/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Data are scarce regarding the virologic impact and safety of immune checkpoint inhibitors (ICI) in patients with chronic hepatitis C virus (HCV) infection. We examined the virologic impact of ICI in HCV-infected patients with solid tumors and their safety. METHODS HCV-infected patients with solid tumor treated with ICI at our institution between April 26, 2016, and January 5, 2022, were enrolled in a prospective observational study. The primary outcomes were ICI-induced changes in HCV viremia (HCV inhibition and HCV reactivation) and safety of ICI. RESULTS We enrolled 52 consecutive patients with solid tumors treated with ICI. Most were men (41; 79%), White (31; 59%), without cirrhosis (34; 65%), and with HCV genotype 1 (40; 77%). Four patients (7.7%) experienced HCV inhibition while receiving ICI including 1 patient who developed undetectable viremia for 6 months in the absence of direct-acting antivirals (DAA). Two patients (4%) developed HCV reactivation, both while receiving immunosuppressive therapy for ICI-related toxic effects. Adverse events occurred in 36 patients (69%), and 39 of the 47 adverse events (83%) were grade 1-2. Grade 3-4 adverse events occurred in 8 patients (15%), and in all cases, they were related to ICI, not to HCV. No HCV-associated liver failure or death occurred. DISCUSSION Inhibition of HCV replication with virologic cure can develop in patients receiving ICI without DAA. HCV reactivation occurs primarily in patients receiving immunosuppressants for ICI-related toxic effects. ICI are safe in HCV-infected patients with solid tumors. Chronic HCV infection should not be considered a contraindication for ICI therapy.
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Affiliation(s)
- Marcel Yibirin
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Khalis Mustafayev
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeff Hosry
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pooja Pundhir
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Klingen
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Yepez Guevara
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bruno P Granwehr
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sapna Patel
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amishi Y Shah
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ferdinandos Skoulidis
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lan Wang
- Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ethan Miller
- Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hao Chi Zhang
- Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amado Zurita-Saavedra
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Harrys A Torres
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Wang J, Zhang B, Peng L, Liu X, Sun J, Su C, Wang H, Zhao Z, Si L, Duan J, Zhang H, Li M, Zhu B, Zhang L, Li J, Guo J, Luo R, Qiu W, Ye D, Chu Q, Cui J, Dong X, Fan Y, Gao Q, Guo Y, He Z, Li W, Lin G, Liu L, Liu Y, Qin H, Ren S, Ren X, Wang Y, Xue J, Yang Y, Yang Z, Yue L, Zhan X, Zhang J, Ma J, Qin S, Wang B. Chinese expert consensus recommendations for the administration of immune checkpoint inhibitors to special cancer patient populations. Ther Adv Med Oncol 2023; 15:17588359231187205. [PMID: 37484525 PMCID: PMC10357053 DOI: 10.1177/17588359231187205] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) targeting programmed cell death 1, programmed cell death ligand 1, and cytotoxic T lymphocyte-associated antigen-4 have shown significantly durable clinical benefits and tolerable toxicities and have improved the survival of patients with various types of cancer. Since 2018, the National Medical Products Administration of China has approved 17 ICIs as the standard treatment for certain advanced or metastatic solid tumors. As ICIs represent a broad-spectrum antitumor strategy, the populations eligible for cancer immunotherapy are rapidly expanding. However, the clinical applications of ICIs in cancer patient populations with special issues, a term that refers to complex subgroups of patients with comorbidities, special clinical conditions, or concomitant medications who are routinely excluded from prospective clinical trials of ICIs or are underrepresented in these trials, represent a great real-world challenge. Although the Chinese Society of Clinical Oncology (CSCO) has provided recommendations for screening before the use of ICIs in special populations, the recommendations for full-course management remain insufficient. The CSCO Expert Committee on Immunotherapy organized leading medical oncology and multidisciplinary experts to develop a consensus that will serve as an important reference for clinicians to guide the proper application of ICIs in special patient populations. This article is a translation of a study first published in Chinese in The Chinese Clinical Oncology (ISSN 1009-0460, CN 32-1577/R) in May 2022 (27(5):442-454). The publisher of the original paper has provided written confirmation of permission to publish this translation in Therapeutic Advances in Medical Oncology.
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Affiliation(s)
- Jun Wang
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital; Shandong Key Laboratory of Rheumatic Disease and Translational Medicine; Shandong Lung Cancer Institute, Jinan 250014, China
| | - Bicheng Zhang
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ling Peng
- Department of Pulmonary and Critical Care Medicine, Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Xiufeng Liu
- Department of Hepatobiliary Oncology, Qinhuai Medical District, Eastern Theater Command General Hospital, Nanjing, China
| | - Jianguo Sun
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Chunxia Su
- Department of Oncology, Shanghai Pulmonary Hospital, Thoracic Cancer Institute, School of Medicine, Tongji University, Shanghai, China
| | - Huijuan Wang
- Department of Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Zheng Zhao
- Department of Oncology, Shannxi Cancer Hospital, Xi’an, China
| | - Lu Si
- Department of Melanoma, Cancer Hospital and Institute, Peking University, Beijing, China
| | - Jianchun Duan
- Department of Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongmei Zhang
- Department of Oncology, Xijing Hospital, Air Force Medical University, Xian, China
| | - Mengxia Li
- Cancer Center, Daping Hospital and Research Institute of Surgery, Army Medical University, Chongqing, China
| | - Bo Zhu
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li Zhang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Jin Li
- Department of Oncology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Jun Guo
- Department of Melanoma, Cancer Hospital and Institute, Peking University, Beijing, China
| | - Rongcheng Luo
- Cancer Center, Jinshazhou Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wensheng Qiu
- Department of Oncology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Dingwei Ye
- Department of Urology, Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Qian Chu
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiuwei Cui
- Department of Oncology, The First Hospital of Jilin University, Changchun, China
| | - Xiaorong Dong
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Fan
- Department of Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Quanli Gao
- Department of Immunology, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Ye Guo
- Department of Oncology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Zhiyong He
- Department of Thoracic Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Wenfeng Li
- Department of Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Gen Lin
- Department of Thoracic Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Lian Liu
- Department of Oncology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yutao Liu
- Department of Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Haifeng Qin
- Department of Oncology, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Shengxiang Ren
- Department of Oncology, Shanghai Pulmonary Hospital, Thoracic Cancer Institute, School of Medicine, Tongji University, Shanghai, China
| | - Xiubao Ren
- Department of Immunology and Biotherapy, Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China
| | - Yongsheng Wang
- GCP Center/Institute of Clinical Pharmacology, West China Hospital, Sichuan University, Chengdu, China
| | - Junli Xue
- Department of Oncology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Yunpeng Yang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Zhenzhou Yang
- Department of Oncology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lu Yue
- Department of Oncology, Qingdao Municipal Hospital, Qingdao, China
| | - Xianbao Zhan
- Department of Oncology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Junping Zhang
- Department of Cancer Biotherapy, Shanxi Bethune Hospital, Taiyuan, China
| | - Jun Ma
- Harbin Institute of Hematology and Oncology, Harbin, China
| | - Shukui Qin
- Department of Hepatobiliary Oncology, Qinhuai Medical District, Eastern Theater Command General Hospital, Nanjing 210008, China
| | - Baocheng Wang
- Department of Oncology, The 960th Hospital, The People’s Liberation Army, Jinan 250031, China
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Apol ÁD, Winckelmann AA, Duus RB, Bukh J, Weis N. The Role of CTLA-4 in T Cell Exhaustion in Chronic Hepatitis B Virus Infection. Viruses 2023; 15:v15051141. [PMID: 37243227 DOI: 10.3390/v15051141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
Patients with chronic hepatitis B (CHB) gradually develop T cell exhaustion, and the inhibitory receptor molecule, cytotoxic T-lymphocyte antigen-4 (CTLA-4), may play a role in this phenomenon. This systematic review investigates the role of CTLA-4 in the development of T cell exhaustion in CHB. A systematic literature search was conducted on PubMed and Embase on 31 March 2023 to identify relevant studies. Fifteen studies were included in this review. A majority of the studies investigating CD8+ T cells demonstrated increased expression of CTLA-4 in CHB patients, though one study found this only in HBeAg-positive patients. Three out of four studies investigating the expression of CTLA-4 on CD4+ T cells found upregulation of CTLA-4. Several studies showed constitutive expression of CLTA-4 on CD4+ regulatory T cells. CTLA-4 blockade resulted in heterogeneous responses for all T cell types, as it resulted in increased T cell proliferation and/or cytokine production in some studies, while other studies found this only when combining blockade of CTLA-4 with other inhibitory receptors. Although mounting evidence supports a role of CTLA-4 in T cell exhaustion, there is still insufficient documentation to describe the expression and exact role of CTLA-4 in T cell exhaustion in CHB.
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Affiliation(s)
- Ása Didriksen Apol
- Department of Infectious Diseases, Copenhagen University Hospital, 2650 Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Copenhagen Hepatitis C Program (CO-HEP), Department of Infectious Diseases, Copenhagen University Hospital, 2650 Hvidovre, Denmark
- Copenhagen Hepatitis C Program (CO-HEP), Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Anni Assing Winckelmann
- Department of Infectious Diseases, Copenhagen University Hospital, 2650 Hvidovre, Denmark
- Copenhagen Hepatitis C Program (CO-HEP), Department of Infectious Diseases, Copenhagen University Hospital, 2650 Hvidovre, Denmark
- Copenhagen Hepatitis C Program (CO-HEP), Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Rasmus Bülow Duus
- Department of Infectious Diseases, Copenhagen University Hospital, 2650 Hvidovre, Denmark
| | - Jens Bukh
- Department of Infectious Diseases, Copenhagen University Hospital, 2650 Hvidovre, Denmark
- Copenhagen Hepatitis C Program (CO-HEP), Department of Infectious Diseases, Copenhagen University Hospital, 2650 Hvidovre, Denmark
- Copenhagen Hepatitis C Program (CO-HEP), Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Nina Weis
- Department of Infectious Diseases, Copenhagen University Hospital, 2650 Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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7
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Efficacy and Safety of Immune Checkpoint Inhibitors in Patients with Cancer and Hepatitis B or C: A Systematic Review and Meta-Analysis. JOURNAL OF ONCOLOGY 2023; 2023:2525903. [PMID: 36647390 PMCID: PMC9840556 DOI: 10.1155/2023/2525903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023]
Abstract
Background Immune checkpoint inhibitors (ICIs) have changed the situation of tumor therapy in recent years. However, for security reasons, those special populations are often excluded from clinical trials, such as infected hepatitis B or hepatitis C patients. ICIs are systematically reviewed and meta-analyzed for the first time in patients infected with hepatitis B or C in this paper. Methods The relevant studies were searched in PubMed, EMBASE, Cochrane Library, and Web of Science until October 2022. Trials and observational studies meeting the inclusion criteria were included. The outcomes included the effectiveness of ICIs in patients with HBC/HCV (ORR, DCR, mOS, and mPFS), the incidence of adverse reactions, high-grade adverse reactions, and abnormal liver enzymes. At the same time, these indexes were compared with those of uninfected patients. Results A total of 2,625 patients were enrolled, involving 1,179 patients with hepatitis (HBV or HCV). We found that ICIs showed higher ORR (25.80% vs. 18.10%) and DCR (66.22% vs. 58.74%) in patients with hepatitis B/C than those without infection. In terms of survival time, patients with hepatitis virus infection showed longer mOS (15.44 m vs. 13.30 m) but shorter mPFS (4.94 m vs. 5.01 m) than uninfected patients. As for safety data, patients with hepatitis showed a lower incidence of all-grade irAEs (68.02% vs. 70.43%) than uninfected patients, while that of 3-4 irAEs (21.27% vs. 21.79%) was similar in the two groups. However, hepatic dysfunction was more common and serious in hepatitis patients. Four HBVr and no HCVr were observed. Conclusion According to this meta-analysis, ICIs are effective and safe for patients with hepatitis B or C, but basic liver enzymes have to be evaluated before treatment to avoid liver adverse events.
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8
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Nakabori T, Abe Y, Higashi S, Hirao T, Kawamoto Y, Maeda S, Daiku K, Urabe M, Kai Y, Takada R, Yamai T, Ikezawa K, Uehara H, Ohkawa K. Feasibility of immunotherapy in cancer patients with persistent or past hepatitis B or C virus infection. JGH OPEN 2022; 6:309-316. [PMID: 35601125 PMCID: PMC9120871 DOI: 10.1002/jgh3.12737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 03/19/2022] [Accepted: 03/24/2022] [Indexed: 12/19/2022]
Affiliation(s)
- Tasuku Nakabori
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Yutaro Abe
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Sena Higashi
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Takeru Hirao
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Yasuharu Kawamoto
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Shingo Maeda
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Kazuma Daiku
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Makiko Urabe
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Yugo Kai
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Ryoji Takada
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Takuo Yamai
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Hiroyuki Uehara
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
| | - Kazuyoshi Ohkawa
- Department of Hepatobiliary and Pancreatic Oncology Osaka International Cancer Institute Osaka Japan
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Shojaie L, Ali M, Iorga A, Dara L. Mechanisms of immune checkpoint inhibitor-mediated liver injury. Acta Pharm Sin B 2021; 11:3727-3739. [PMID: 35024302 PMCID: PMC8727893 DOI: 10.1016/j.apsb.2021.10.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 12/16/2022] Open
Abstract
The immune checkpoints, cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death protein-1/ligand-1 (PD-1/PD-L1) are vital contributors to immune regulation and tolerance. Recently immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy; however, they come with the cost of immune related adverse events involving multiple organs such as the liver. Due to its constant exposure to foreign antigens, the liver has evolved a high capacity for immune tolerance, therefore, blockade of the immune checkpoints can result in aberrant immune activation affecting the liver in up to 20% of patients depending on the agent(s) used and underlying factors. This type of hepatotoxicity is termed immune mediated liver injury from checkpoint inhibitors (ILICI) and is more common when CTLA4 and PD-1/PD-L1 are used in combination. The underlying mechanisms of this unique type of hepatotoxicity are not fully understood; however, the contribution of CD8+ cytotoxic T lymphocytes, various CD4+ T cells populations, cytokines, and the secondary activation of the innate immune system leading to liver injury have all been suggested. This review summarizes our current understanding of the underlying mechanisms of liver injury in immunotherapy using animal models of ILICI and available patient data from clinical studies.
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Affiliation(s)
- Layla Shojaie
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Research Center for Liver Disease, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Myra Ali
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Andrea Iorga
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Research Center for Liver Disease, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- U.S. Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD 20993, USA
- UMBC Center for Accelerated Real Time Analytics, University of Maryland, Baltimore County, Baltimore, MD 21250, USA
| | - Lily Dara
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Research Center for Liver Disease, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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10
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da Silva JA, Falcão D, Cardoso C, Pires AL, Araújo A, Castro-Poças F. Hepatic immune-mediatedadverseeffects of immune checkpoint inhibitors: analysis of real-life experience. Ann Hepatol 2021; 26:100561. [PMID: 34653687 DOI: 10.1016/j.aohep.2021.100561] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Immune Checkpoint Inhibitors (ICI) have shifted the paradigm of cancer therapy treatment. Despite their efficacy, ICIs may induce immune-related adverse events (irAE), which can affect various organs, namely the liver. This study intends to perform a comprehensive clinical description of the hepatic irAEs associated with ICI in a Portuguese population of a tertiary hospital centre. MATERIALS AND METHODS A retrospective analysis of patients who developed immune-mediated liver injury (IMLI), among a cohort of patients treated with ICIs between March 15th of 2015 and December 15th of 2019 in a tertiary hospital. We used both Common Terminology Criteria for Adverse Events (CTCAE) and Drug-Induced Liver Injury Network (DILIN) criteria to define liver injury. RESULTS Among 151 patients, eight (5.3%) patients developed liver injury grade ≥3, of which five had hepatic metastasis. As such, only 3 cases were classified as IMLI. All IMLI presented with cholestasis pattern; the median duration from ICI initiation to IMLI was 84 days and/or 4 ICI cycles; one patient registered IMLI one month after nivolumab suspension; all were treated with steroids and one was successfully submitted to ICI re-challenge; a favourable outcome was seen in all patients; the median time to hepatic biochemistries normalization was 150 days. Among 10 patients with previous hepatic conditions, only one developed liver injury grade 2. CONCLUSIONS Clinically significant ICI-related hepatotoxicity was uncommon; Immune-mediated liver injury may present a cholestatic pattern predominance. There was a low rate of liver injury of any kind in patients with previous hepatic disease while on ICI.
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Affiliation(s)
| | - Daniela Falcão
- Gastroenterology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Cláudia Cardoso
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
| | - Ana Luísa Pires
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
| | - António Araújo
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal; Oncology Service, Pathology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Fernando Castro-Poças
- Gastroenterology, Centro Hospitalar Universitário do Porto, Porto, Portugal; Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
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11
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Bartoli A, Gabrielli F, Tassi A, Cursaro C, Pinelli A, Andreone P. Treatments for HBV: A Glimpse into the Future. Viruses 2021; 13:1767. [PMID: 34578347 PMCID: PMC8473442 DOI: 10.3390/v13091767] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 12/16/2022] Open
Abstract
The hepatitis B virus is responsible for most of the chronic liver disease and liver cancer worldwide. As actual therapeutic strategies have had little success in eradicating the virus from hepatocytes, and as lifelong treatment is often required, new drugs targeting the various phases of the hepatitis B virus (HBV) lifecycle are currently under investigation. In this review, we provide an overview of potential future treatments for HBV.
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Affiliation(s)
- Alessandra Bartoli
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, 41126 Modena, Italy; (A.B.); (F.G.); (A.T.); (C.C.); (A.P.)
- Postgraduate School of Allergy and Clinical Immunology, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Filippo Gabrielli
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, 41126 Modena, Italy; (A.B.); (F.G.); (A.T.); (C.C.); (A.P.)
- Postgraduate School of Internal Medicine, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Andrea Tassi
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, 41126 Modena, Italy; (A.B.); (F.G.); (A.T.); (C.C.); (A.P.)
- Postgraduate School of Internal Medicine, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Carmela Cursaro
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, 41126 Modena, Italy; (A.B.); (F.G.); (A.T.); (C.C.); (A.P.)
| | - Ambra Pinelli
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, 41126 Modena, Italy; (A.B.); (F.G.); (A.T.); (C.C.); (A.P.)
- Postgraduate School of Allergy and Clinical Immunology, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, 41126 Modena, Italy; (A.B.); (F.G.); (A.T.); (C.C.); (A.P.)
- Postgraduate School of Allergy and Clinical Immunology, University of Modena and Reggio Emilia, 41126 Modena, Italy
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12
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Rzeniewicz K, Larkin J, Menzies AM, Turajlic S. Immunotherapy use outside clinical trial populations: never say never? Ann Oncol 2021; 32:866-880. [PMID: 33771665 PMCID: PMC9246438 DOI: 10.1016/j.annonc.2021.03.199] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Based on favourable outcomes in clinical trials, immune checkpoint inhibitors (ICIs), most notably programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4) inhibitors, are now widely used across multiple cancer types. However, due to their strict inclusion and exclusion criteria, clinical studies often do not address challenges presented by non-trial populations. DESIGN This review summarises available data on the efficacy and safety of ICIs in trial-ineligible patients, including those with autoimmune disease, chronic viral infections, organ transplants, organ dysfunction, poor performance status, and brain metastases, as well as the elderly, children, and those who are pregnant. In addition, we review data concerning other real-world challenges with ICIs, including timing of therapy switch, relationships to radiotherapy or surgery, re-treatment after an immune-related toxicity, vaccinations in patients on ICIs, and current experience around ICI and coronavirus disease-19. Where possible, we provide recommendations to aid the often-difficult decision-making process in those settings. CONCLUSIONS Data suggest that ICIs are often active and have an acceptable safety profile in the populations described above, with the exception of PD-1 inhibitors in solid organ transplant recipients. Decisions about whether to treat with ICIs should be personalised and require multidisciplinary input and careful counselling of patients with respect to potential risks and benefits. Clinical judgements need to be carefully weighed, considering factors such as underlying cancer type, feasibility of alternative treatment options, or activity in trial-eligible patients.
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Affiliation(s)
- K Rzeniewicz
- Warwick Medical School, University of Warwick, Warwick, UK; Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - J Larkin
- Renal and Skin Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - A M Menzies
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia; Royal North Shore and Mater Hospitals, Sydney, Australia
| | - S Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK; Renal and Skin Units, The Royal Marsden NHS Foundation Trust, London, UK.
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13
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Granito A, Muratori L, Lalanne C, Quarneti C, Ferri S, Guidi M, Lenzi M, Muratori P. Hepatocellular carcinoma in viral and autoimmune liver diseases: Role of CD4+ CD25+ Foxp3+ regulatory T cells in the immune microenvironment. World J Gastroenterol 2021; 27:2994-3009. [PMID: 34168403 PMCID: PMC8192285 DOI: 10.3748/wjg.v27.i22.2994] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/09/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
More than 90% of cases of hepatocellular carcinoma (HCC) occurs in patients with cirrhosis, of which hepatitis B virus and hepatitis C virus are the leading causes, while the tumor less frequently arises in autoimmune liver diseases. Advances in understanding tumor immunity have led to a major shift in the treatment of HCC, with the emergence of immunotherapy where therapeutic agents are used to target immune cells rather than cancer cells. Regulatory T cells (Tregs) are the most abundant suppressive cells in the tumor microenvironment and their presence has been correlated with tumor progression, invasiveness, as well as metastasis. Tregs are characterized by the expression of the transcription factor Foxp3 and various mechanisms ranging from cell-to-cell contact to secretion of inhibitory molecules have been implicated in their function. Notably, Tregs amply express checkpoint molecules such as cytotoxic T lymphocyte-associated antigen 4 and programmed cell-death 1 receptor and therefore represent a direct target of immune checkpoint inhibitor (ICI) immunotherapy. Taking into consideration the critical role of Tregs in maintenance of immune homeostasis as well as avoidance of autoimmunity, it is plausible that targeting of Tregs by ICI immunotherapy results in the development of immune-related adverse events (irAEs). Since the use of ICI becomes common in oncology, with an increasing number of new ICI currently under clinical trials for cancer treatment, the occurrence of irAEs is expected to dramatically rise. Herein, we review the current literature focusing on the role of Tregs in HCC evolution taking into account their opposite etiological function in viral and autoimmune chronic liver disease, and we discuss their involvement in irAEs due to the new immunotherapies.
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Affiliation(s)
- Alessandro Granito
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna 40138, Italy
- Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Luigi Muratori
- Division of Internal Medicine and Immunorheumatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, University of Bologna, Bologna 40138, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Claudine Lalanne
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, Bologna 40138, Italy
| | - Chiara Quarneti
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, Bologna 40138, Italy
| | - Silvia Ferri
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, Bologna 40138, Italy
| | - Marcello Guidi
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, Bologna 40138, Italy
| | - Marco Lenzi
- Division of Internal Medicine and Immunorheumatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, University of Bologna, Bologna 40138, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Paolo Muratori
- Division of Internal Medicine, Morgagni-Pierantoni Hospital, Forlì 47100, Italy
- Department of Science for the Quality of Life, University of Bologna, Bologna 40138, Italy
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14
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De Keukeleire SJ, Vermassen T, Nezhad ZM, Kerre T, Kruse V, Vlierberghe HV, Vermaelen K, Rottey S. Managing viral hepatitis in cancer patients under immune checkpoint inhibitors: should we take the risk? Immunotherapy 2021; 13:409-418. [PMID: 33487052 DOI: 10.2217/imt-2020-0273] [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: 12/26/2022] Open
Abstract
More patients with chronic hepatitis B and C infection are being exposed to immune checkpoint inhibitors (ICIs), but the safety and efficacy of ICIs in patients with chronic viral hepatitis are still poorly described. To explore this interaction, we identified eight studies of cancer patients with viral hepatitis treated with one or more ICIs, formally assessed tumor responses and safety by grading liver dysfunction. ICIs appear to be relatively safe in HBV/HCV-infected patients, and hepatitis related to viral reactivation is rare. In some patients, viral load regressed during ICI treatment, so immune checkpoints may play a role in viral clearance. HBV/HCV do not appear to be a contraindication to ICIs, although careful clinical and biochemical follow-up is recommended and, whenever necessary, antiviral therapy commenced.
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Affiliation(s)
| | - Tijl Vermassen
- Drug Research Unit Ghent, Ghent University Hospital, Gent 9000, Belgium
| | - Zahra M Nezhad
- Drug Research Unit Ghent, Ghent University Hospital, Gent 9000, Belgium
| | - Tessa Kerre
- Department of Hematology, Ghent University Hospital, Gent 9000, Belgium
| | - Vibeke Kruse
- Department of Lung Diseases-Thoracic Oncology, Gent University Hospital, Gent 9000, Belgium
| | | | - Karim Vermaelen
- Department of Gastroenterology & Hepatology, Ghent University Hospital, Gent 9000, Belgium
| | - Sylvie Rottey
- Department of Medical Oncology, Ghent University Hospital, Gent 9000, Belgium.,Drug Research Unit Ghent, Ghent University Hospital, Gent 9000, Belgium
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15
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Regev A, Avigan MI, Kiazand A, Vierling JM, Lewis JH, Omokaro SO, Di Bisceglie AM, Fontana RJ, Bonkovsky HL, Freston JW, Uetrecht JP, Miller ED, Pehlivanov ND, Haque SA, Harrison MJ, Kullak-Ublick GA, Li H, Patel NN, Patwardhan M, Price KD, Watkins PB, Chalasani NP. Best practices for detection, assessment and management of suspected immune-mediated liver injury caused by immune checkpoint inhibitors during drug development. J Autoimmun 2020; 114:102514. [DOI: 10.1016/j.jaut.2020.102514] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
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16
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Alexopoulou A, Vasilieva L, Karayiannis P. New Approaches to the Treatment of Chronic Hepatitis B. J Clin Med 2020; 9:jcm9103187. [PMID: 33019573 PMCID: PMC7601587 DOI: 10.3390/jcm9103187] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023] Open
Abstract
The currently recommended treatment for chronic hepatitis B virus (HBV) infection achieves only viral suppression whilst on therapy, but rarely hepatitis B surface antigen (HBsAg) loss. The ultimate therapeutic endpoint is the combination of HBsAg loss, inhibition of new hepatocyte infection, elimination of the covalently closed circular DNA (cccDNA) pool, and restoration of immune function in order to achieve virus control. This review concentrates on new antiviral drugs that target different stages of the HBV life cycle (direct acting antivirals) and others that enhance both innate and adaptive immunity against HBV (immunotherapy). Drugs that block HBV hepatocyte entry, compounds that silence or deplete the cccDNA pool, others that affect core assembly, agents that degrade RNase-H, interfering RNA molecules, and nucleic acid polymers are likely interventions in the viral life cycle. In the immunotherapy category, molecules that activate the innate immune response such as Toll-like-receptors, Retinoic acid Inducible Gene-1 (RIG-1) and stimulator of interferon genes (STING) agonists or checkpoint inhibitors, and modulation of the adaptive immunity by therapeutic vaccines, vector-based vaccines, or adoptive transfer of genetically-engineered T cells aim towards the restoration of T cell function. Future therapeutic trends would likely be a combination of one or more of the aforementioned drugs that target the viral life cycle and at least one immunomodulator.
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Affiliation(s)
- Alexandra Alexopoulou
- Department of Medicine, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece;
- Correspondence: ; Tel.: +30-2132-088-178; Fax: +30-2107-706-871
| | - Larisa Vasilieva
- Department of Medicine, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece;
| | - Peter Karayiannis
- Department of Basic and Clinical Sciences, Medical School, University of Nicosia, Engomi, CY-1700 Nicosia, Cyprus;
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17
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De Martin E, Michot JM, Rosmorduc O, Guettier C, Samuel D. Liver toxicity as a limiting factor to the increasing use of immune checkpoint inhibitors. JHEP Rep 2020; 2:100170. [PMID: 33205034 PMCID: PMC7648167 DOI: 10.1016/j.jhepr.2020.100170] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) improve clinical outcomes in patients suffering from different types of cancer. Liver toxicity is one of the immune-related adverse events associated with immunotherapy; although not common, its management is challenging as it is extremely heterogeneous in terms of presentation and severity. Differences in the development and evolution of ICI-related toxicity in healthy or cirrhotic livers have not yet been elucidated. Assessing causality is key to diagnosing ICI-induced liver toxicity; liver biopsies can assist not only in the differential diagnosis but also in assessing the severity of histological liver damage. The current classification of severity overestimates the grade of liver injury and needs to be revised to reflect the views of hepatologists. Spontaneous improvements in ICI-related liver toxicity have been reported, so corticosteroid therapy should probably be individualised not systematic. The reintroduction of ICIs in a patient with previous immune-mediated hepatitis may be possible, but the risk/benefit ratio should be considered, as the risk factors for hepatitis recurrence are currently unclear. The management of these patients, requiring a balance between efficacy, toxicity and specific treatments, necessitates multidisciplinary collaboration. The incidence of immune-related liver toxicity will continue to rise based on the increasing use of ICIs for most cancers, mandating improved understanding and management of this complication.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AMA, anti-mitochondrial antibodies
- ANA, anti-nuclear antibodies
- ASMA, anti-smooth muscles antibodies
- AST, aspartate aminotransferase
- CTLA-4, cytotoxic T lymphocyte-associated protein 4
- Corticosteroid therapy
- DCR, disease control rate
- DILI, drug-induced liver injury
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- ICI, immune checkpoint inhibitor
- INR, international normalised ratio
- Immune-mediated hepatitis
- Immunotherapy
- Liver biopsy
- MMF, mycophenolate mofetil
- ORR, objective response rate
- OS, overall survival
- PD-1, programmed cell death 1
- PD-L1-2, programmed cell death ligands 1-2
- PFS, progression-free survival
- TKI, tyrosine kinase inhibitor
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
- anti-LC1, anti-liver cytosol type-1 antibodies
- anti-LKM, anti-liver-kidney microsomal antibodies
- anti-SLA, anti-soluble liver antigen antibodies
- irAE, immune-related adverse event
- trAE, treatment-related adverse event
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Affiliation(s)
- Eleonora De Martin
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France
| | - Jean-Marie Michot
- Département d'innovation thérapeutique et d'Essais Précoces (DITEP), Institut Gustave-Roussy, Université Paris Saclay, Villejuif, France
| | - Olivier Rosmorduc
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France.,Sorbonne-Université
| | - Catherine Guettier
- AP-HP Hôpital Bicêtre, Laboratoire Anatomie Pathologique, Le Kremlin-Bicêtre, France, Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France
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18
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Schön MP, Berking C, Biedermann T, Buhl T, Erpenbeck L, Eyerich K, Eyerich S, Ghoreschi K, Goebeler M, Ludwig RJ, Schäkel K, Schilling B, Schlapbach C, Stary G, von Stebut E, Steinbrink K. COVID-19 and immunological regulations - from basic and translational aspects to clinical implications. J Dtsch Dermatol Ges 2020; 18:795-807. [PMID: 32761894 PMCID: PMC7436872 DOI: 10.1111/ddg.14169] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The COVID‐19 pandemic caused by SARS‐CoV‐2 has far‐reaching direct and indirect medical consequences. These include both the course and treatment of diseases. It is becoming increasingly clear that infections with SARS‐CoV‐2 can cause considerable immunological alterations, which particularly also affect pathogenetically and/or therapeutically relevant factors. Against this background we summarize here the current state of knowledge on the interaction of SARS‐CoV‐2/COVID‐19 with mediators of the acute phase of inflammation (TNF, IL‐1, IL‐6), type 1 and type 17 immune responses (IL‐12, IL‐23, IL‐17, IL‐36), type 2 immune reactions (IL‐4, IL‐13, IL‐5, IL‐31, IgE), B‐cell immunity, checkpoint regulators (PD‐1, PD‐L1, CTLA4), and orally druggable signaling pathways (JAK, PDE4, calcineurin). In addition, we discuss in this context non‐specific immune modulation by glucocorticosteroids, methotrexate, antimalarial drugs, azathioprine, dapsone, mycophenolate mofetil and fumaric acid esters, as well as neutrophil granulocyte‐mediated innate immune mechanisms. From these recent findings we derive possible implications for the therapeutic modulation of said immunological mechanisms in connection with SARS‐CoV‐2/COVID‐19. Although, of course, the greatest care should be taken with patients with immunologically mediated diseases or immunomodulating therapies, it appears that many treatments can also be carried out during the COVID‐19 pandemic; some even appear to alleviate COVID‐19.
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Affiliation(s)
- Michael P Schön
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Germany.,Lower Saxony Institute of Occupational Dermatology, University Medical Center Göttingen, Germany
| | - Carola Berking
- Department of Dermatology, University Medical Center Erlangen, Deutsches Zentrum Immuntherapie, Friedrich Alexander University Erlangen-Nürnberg, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergy Biederstein, Technical University Munich, Germany
| | - Timo Buhl
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Germany.,Lower Saxony Institute of Occupational Dermatology, University Medical Center Göttingen, Germany
| | - Luise Erpenbeck
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Germany
| | - Kilian Eyerich
- Department of Dermatology and Allergy Biederstein, Technical University Munich, Germany.,Department of Medicine Solna, Unit of Dermatology and Venereology, Karolinska Institutet, Stockholm, Sweden
| | - Stefanie Eyerich
- ZAUM - Center of Allergy and Environment, Technical University and Helmholtz Center Munich, Germany
| | - Kamran Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité - University Medical Center Berlin, Germany
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Germany
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Germany
| | - Knut Schäkel
- Department of Dermatology, University Medical Center Heidelberg, Germany
| | - Bastian Schilling
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Germany
| | - Christoph Schlapbach
- Department of Dermatology, Inselspital University Medical Center, Bern, Switzerland
| | - Georg Stary
- Department of Dermatology, Medical University of Vienna, Austria
| | | | - Kerstin Steinbrink
- Department of Dermatology, Westfälische Wilhelms University Münster, Germany
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19
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Schön MP, Berking C, Biedermann T, Buhl T, Erpenbeck L, Eyerich K, Eyerich S, Ghoreschi K, Goebeler M, Ludwig RJ, Schäkel K, Schilling B, Schlapbach C, Stary G, von Stebut E, Steinbrink K. COVID‐19 und Immunregulation – von grundlegenden und translationalen Aspekten zu klinischen Implikationen. J Dtsch Dermatol Ges 2020; 18:795-809. [PMID: 32881300 PMCID: PMC7461193 DOI: 10.1111/ddg.14169_g] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/20/2020] [Indexed: 01/08/2023]
Abstract
Die durch SARS‐CoV‐2 verursachte Pandemie COVID‐19 hat weitreichende direkte und indirekte medizinische Folgen. Dazu gehören sowohl der Verlauf als auch die Behandlung vieler Krankheiten. Es wird immer deutlicher, dass Infektionen mit SARS‐CoV‐2 erhebliche immunologische Veränderungen verursachen können, die insbesondere auch pathogenetisch und/oder therapeutisch relevante Faktoren betreffen. Vor diesem Hintergrund fassen wir hier den aktuellen Wissensstand zur Interaktion von SARS‐CoV‐2/COVID‐19 mit Mediatoren der akuten Phase der Entzündung (TNF, IL‐1, IL‐6), der Typ‐1‐ und Typ‐17‐Immunantwort (IL‐12, IL‐23, IL‐17, IL‐36), Typ‐2‐Immunreaktionen (IL‐4, IL‐13, IL‐5, IL‐31, IgE), B‐Zell‐Immunität, Checkpoint‐Regulatoren (PD‐1, PD‐L1, CTLA4) und Signalwegen, die durch oral applizierte Medikamente moduliert werden (JAK, PDE4, Calcineurin), zusammen. Darüber hinaus diskutieren wir in diesem Zusammenhang die unspezifische Immunmodulation durch Glukokortikosteroide, Methotrexat, Malariamittel, Azathioprin, Dapson, Mycophenolsäure‐Derivate und Fumarsäureester sowie angeborene Immunmechanismen neutrophiler Granulozyten. Aus diesen neueren Erkenntnissen leiten wir mögliche Implikationen für die therapeutische Modulation der genannten immunologischen Mechanismen im Zusammenhang mit SARS‐CoV‐2/COVID‐19 ab. Obwohl natürlich bei Patienten mit immunologisch vermittelten Krankheiten oder immunmodulierenden Therapien größte Vorsicht geboten ist, scheint es, dass viele Behandlungen auch während der COVID‐19‐Pandemie durchgeführt werden können; einige scheinen COVID‐19 sogar zu lindern.
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Affiliation(s)
- Michael P. Schön
- Klinik für DermatologieVenerologie und AllergologieUniversitätsmedizin GöttingenDeutschland
- Niedersächsisches Institut für BerufsdermatologieUniversitätsmedizin GöttingenDeutschland
| | - Carola Berking
- HautklinikUniversitätsklinikum ErlangenDeutsches Zentrum ImmuntherapieFriedrich‐Alexander‐Universität Erlangen‐NürnbergDeutschland
| | - Tilo Biedermann
- Klinik für Dermatologie und Allergie BiedersteinTechnische Universität MünchenDeutschland
| | - Timo Buhl
- Klinik für DermatologieVenerologie und AllergologieUniversitätsmedizin GöttingenDeutschland
- Niedersächsisches Institut für BerufsdermatologieUniversitätsmedizin GöttingenDeutschland
| | - Luise Erpenbeck
- Klinik für DermatologieVenerologie und AllergologieUniversitätsmedizin GöttingenDeutschland
| | - Kilian Eyerich
- Klinik für Dermatologie und Allergie BiedersteinTechnische Universität MünchenDeutschland
- Department of Medicine SolnaUnit of Dermatology and VenereologyKarolinska InstitutetStockholmSchweden
| | - Stefanie Eyerich
- ZAUM – Zentrum für Allergie und UmweltTechnische Universität MünchenDeutschland
| | - Kamran Ghoreschi
- Klinik für DermatologieVenerologie und AllergologieCharité – Universitätsmedizin BerlinDeutschland
| | - Matthias Goebeler
- Klinik für DermatologieVenerologie und AllergologieUniversitätsklinikum WürzburgDeutschland
| | - Ralf J. Ludwig
- Lübeck Institut für Experimentelle DermatologieUniversität LübeckDeutschland
| | - Knut Schäkel
- HautklinikUniversitätsklinikum HeidelbergDeutschland
| | - Bastian Schilling
- Klinik für DermatologieVenerologie und AllergologieUniversitätsklinikum WürzburgDeutschland
| | | | - Georg Stary
- Klinik für DermatologieMedizinische Universität WienÖsterreich
| | | | - Kerstin Steinbrink
- Klinik für DermatologieWestfälische Wilhelms‐Universität MünsterDeutschland
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de La Rochefoucauld J, Noël N, Lambotte O. Management of immune-related adverse events associated with immune checkpoint inhibitors in cancer patients: a patient-centred approach. Intern Emerg Med 2020; 15:587-598. [PMID: 32144552 DOI: 10.1007/s11739-020-02295-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 02/13/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment. The number of indications is increasing and antibodies targeting the CTLA-4 and PD-1/PD-L1 pathways are now also prescribed in adjuvant settings and for metastatic cancer. However, ICIs reactivate autoreactive immune cells as well as tumour-specific T cells, which lead to immune-related adverse events (irAEs) in around 70% of treated patients. Although all organs can potentially be involved, the skin, gut, thyroid, lungs, liver, and joints are most frequently affected. Most irAEs occur in the first few months of treatment but late-onset toxicity-even after the ICI has been discontinued-is also possible. In terms of severity, most irAEs are grade 1-2. Some irAEs (especially myocarditis, pneumonitis, and encephalitis) are potentially fatal; in patients with highly suggestive clinical signs, treatment should be initiated before the diagnostic work-up has been completed. When confronted with an unexpected clinical sign, the physician must differentiate rapidly between an irAE, cancer progression, and another (unrelated) cause. The management of irAEs is based on the temporary or permanent discontinuation of the ICI and (for grade ≥ 2 events) the administration of steroids.
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Affiliation(s)
- Jeanne de La Rochefoucauld
- Department of Internal Medicine and Clinical Immunology, APHP-Université-Paris-Saclay, Hôpital Universitaire Bicêtre, CHU Bicêtre, APHP, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Nicolas Noël
- Department of Internal Medicine and Clinical Immunology, APHP-Université-Paris-Saclay, Hôpital Universitaire Bicêtre, CHU Bicêtre, APHP, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
- INSERM U1184, Immunology of Viral Infections and Autoimmune Diseases, 94276, Le Kremlin Bicêtre, France
- Université Paris Saclay, UMR 1184, 94276, Le Kremlin Bicêtre, France
- CEA, DSV/iMETI, IDMIT, 92265, Fontenay-aux-Roses, France
| | - Olivier Lambotte
- Department of Internal Medicine and Clinical Immunology, APHP-Université-Paris-Saclay, Hôpital Universitaire Bicêtre, CHU Bicêtre, APHP, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.
- INSERM U1184, Immunology of Viral Infections and Autoimmune Diseases, 94276, Le Kremlin Bicêtre, France.
- Université Paris Saclay, UMR 1184, 94276, Le Kremlin Bicêtre, France.
- CEA, DSV/iMETI, IDMIT, 92265, Fontenay-aux-Roses, France.
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The safety and efficacy of immune checkpoint inhibitors in patients with advanced cancers and pre-existing chronic viral infections (Hepatitis B/C, HIV): A review of the available evidence. Cancer Treat Rev 2020; 86:102011. [PMID: 32213376 DOI: 10.1016/j.ctrv.2020.102011] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/15/2020] [Accepted: 03/15/2020] [Indexed: 12/30/2022]
Abstract
The treatment paradigm of several cancers has dramatically changed in recent years with the introduction of immunotherapy. Most oncology trials involving immune checkpoint inhibitors (ICIPs) have routinely excluded patients with HIV infection and chronic viral hepatitis B (HBV) and C (HCV) due to concerns about viral reactivation, fears of increased toxicity, and the potential lack of efficacy in these patient subgroups. However, with current antiviral therapies, HIV and HBV infections have become chronic diseases and HCV infections can even be cured. Broadening cancer trial eligibility criteria in order to include cancer patients with chronic viral infections can maximize the ecological validity of study results and the ability to understand the ICPIs' benefit-risk profile in patients with these comorbidities. In this review, we examined the evidence on the efficacy and safety of using ICPIs in cancer patients with concurrent chronic viral infections.
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Pertejo-Fernandez A, Ricciuti B, Hammond SP, Marty FM, Recondo G, Rangachari D, Costa DB, Awad MM. Safety and efficacy of immune checkpoint inhibitors in patients with non-small cell lung cancer and hepatitis B or hepatitis C infection. Lung Cancer 2020; 145:181-185. [PMID: 32423643 DOI: 10.1016/j.lungcan.2020.02.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/14/2020] [Accepted: 02/20/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The safety and efficacy of immunotherapy among patients with history of hepatitis B (HBV) or hepatitis C virus (HCV) infection and non-small cell lung cancer (NSCLC) remains unclear as this population has traditionally been excluded from clinical trials with immune checkpoint inhibitors (ICIs). MATERIALS AND METHODS We retrospectively evaluated treatment toxicities and clinical outcomes in nineteen patients with NSCLC and history of past or chronic HBV (16 cases, two of these had HCV co-infection) or chronic HCV infection (five cases), who received a programmed death-1 (PD-1) pathway inhibitor. RESULTS The overall response rate to immunotherapy was 35 %, and the median progression-free survival was 4.5 months. After ICI initiation, increases in liver function tests (LFTs) from baseline were infrequent and mild, and no patients experienced grade 3 or 4 hepatic immune-related adverse events or required ICI discontinuation or corticosteroid administration for management of hepatic toxicity. There were no significant changes in viral load or cases of HBV reactivation or HCV flare while on ICI therapy. CONCLUSION In this case series, treatment with immunotherapy in patients with NSCLC and past or chronic viral hepatitis appears to be safe, and responses to ICIs can be durable in this population. Additional studies are needed in larger cohorts of patients to determine the safety of immunotherapy in patients with chronic viral infections.
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Affiliation(s)
- Ana Pertejo-Fernandez
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Biagio Ricciuti
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Sarah P Hammond
- Division of Infectious Disease, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Francisco M Marty
- Division of Infectious Disease, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gonzalo Recondo
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Deepa Rangachari
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Daniel B Costa
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Mark M Awad
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States.
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Pu D, Yin L, Zhou Y, Li W, Huang L, Cai L, Zhou Q. Safety and efficacy of immune checkpoint inhibitors in patients with HBV/HCV infection and advanced-stage cancer: A systematic review. Medicine (Baltimore) 2020; 99:e19013. [PMID: 32000444 PMCID: PMC7004734 DOI: 10.1097/md.0000000000019013] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cancer patients with hepatitis B or C virus (HBV/HCV) infection are commonly seen in clinical practice, however, the data of safety and efficacy of immune checkpoint inhibitors (ICIs) among them are sparse, because active HBV/HCV infected patients were generally excluded by clinical trials and the correlation between previous infection and treatment-related adverse events was rarely reported. This review is the first to summarize the results on the safety and efficacy of immune checkpoint inhibitors (ICIs) in HBV/HCV infected cancer patients. METHOD We searched literature and conference abstracts in PubMed and Embase followed the PRISMA guideline, using the keywords hepatitis B, hepatitis C, immune checkpoint inhibitor, ipilimumab, nivolumab, pembrolizumab, atezolizumab, durvalumab, avelumab, tremelimumab. Studies described patients with HBV/HCV infection treated with ICIs for advanced stage cancer were included. FINDINGS One hundred eighty six patients were identified from 14 articles (8 case reports, 4 case series, 2 trials). Eighty nine patients had HBV infection and 98 had HCV infection (1 both had HBV and HCV). The majority of patients were treated with PD-1 inhibitor monotherapy (140 of 186, 75.3%) and anti-CTLA-4 monotherapy (36 of 186, 19.4%). No treatment-related death was reported. The incidence of grade 3 or 4 hepatic transaminase elevating (HTE) in HBV and HCV infected patients were 3.4% (3/89) and 17.3% (17/98), respectively. 2.8% patients without antivirus therapy experienced virus load increasing, and 1.9% presented virus-related hepatitis. In terms of efficacy, 22 of 118 (18.6%) patients with liver cancer, 11 of 34 (32.4%) with melanoma, 1 of 6 (16.7%) with NSCLC showed objective responses (CR and PR) to ICIs in spite of lines of therapies. CONCLUSION ICIs is considered to be safe and effective in advanced cancer patients with hepatitis B or C infection, but still has possibilities to reactive hepatitis virus due to uncertain mechanisms. We recommend that those with viral hepatitis be monitored closely and treated with antiviral therapy if indicated before or during ICIs treatment.
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Affiliation(s)
- Dan Pu
- Lung Cancer Center of West China Hospital
| | - Liyuan Yin
- Lung Cancer Center of West China Hospital
| | - Yuwen Zhou
- Department of Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wen Li
- Lung Cancer Center of West China Hospital
| | - Lin Huang
- Lung Cancer Center of West China Hospital
| | - Liang Cai
- Lung Cancer Center of West China Hospital
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Jennings JJ, Mandaliya R, Nakshabandi A, Lewis JH. Hepatotoxicity induced by immune checkpoint inhibitors: a comprehensive review including current and alternative management strategies. Expert Opin Drug Metab Toxicol 2019; 15:231-244. [PMID: 30677306 DOI: 10.1080/17425255.2019.1574744] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) block cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1)/PD ligand 1 (PD-L1) receptors that control antitumor activities of lymphocytes. While highly efficacious, these drugs have been associated with several immune-related adverse events (irAEs) due to the disruption of self-tolerance. Immune-mediated hepatitis (IMH) usually presents as mild elevations of liver enzymes though it can rarely be associated with life-threatening hepatic injury. Areas covered: A comprehensive review was performed to define the clinicopathologic forms of liver injury associated with ICIs, comparing the various ICI classes as well as comparing this form of IMH with idiopathic autoimmune hepatitis and drug-induced autoimmune hepatitis. Liver biopsy has proven very useful in selected patients. A specific form of fibrin ring granulomatous hepatitis appears to be associated with IMH. The current societal treatment algorithms and emerging data were reviewed to determine when to utilize corticosteroids. Expert opinion: Monitoring for severe ICI-IMH is recommended although acute liver failure remains rare. Most patients with grade 3-4 hepatotoxicity respond to corticosteroids, but a subset of patients with mild hepatitis on liver biopsy resolve without steroids and need to be carefully selected in concert with the consultation of a hepatologist.
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Affiliation(s)
- Joseph J Jennings
- a Department of Medicine, Division of Gastroenterology and Hepatology , MedStar Georgetown University Hospital , Washington , DC , USA
| | - Rohan Mandaliya
- a Department of Medicine, Division of Gastroenterology and Hepatology , MedStar Georgetown University Hospital , Washington , DC , USA
| | - Ahmad Nakshabandi
- b Department of Internal Medicine , Mercy Hospital and Medical Center , Chicago , IL , USA
| | - James H Lewis
- a Department of Medicine, Division of Gastroenterology and Hepatology , MedStar Georgetown University Hospital , Washington , DC , USA
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26
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Arenbergerova M, Fialova A, Arenberger P, Gkalpakiotis S, Pasek M, Putzova M. Targeted treatment of metastatic melanoma in a drug-addicted patient with pre-existing hepatitis C. Dermatol Ther 2018; 32:e12790. [PMID: 30499152 DOI: 10.1111/dth.12790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 11/26/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Monika Arenbergerova
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alena Fialova
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Arenberger
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Spyridon Gkalpakiotis
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marek Pasek
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Grant MJ, DeVito N, Salama AKS. Checkpoint inhibitor use in two heart transplant patients with metastatic melanoma and review of high-risk populations. Melanoma Manag 2018; 5:MMT10. [PMID: 30459942 PMCID: PMC6240846 DOI: 10.2217/mmt-2018-0004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/03/2018] [Indexed: 12/12/2022] Open
Abstract
Due to the unique side-effect profile of immune checkpoint inhibitors (ICIs), groups of patients deemed to be at high risk of complications were excluded from trials that proved the efficacy and safety of these agents in patients with various malignancies. Among these excluded patients were those with prior solid organ transplantation, chronic viral infections and pre-existing autoimmune diseases including paraneoplastic syndromes. We present follow-up on a patient from a previously published case report with an orthotopic heart transplantation who was treated with both cytotoxic T-lymphocyte antigen 4 and PD-1 inhibition safely, without organ rejection. Additionally, we describe the case of a patient with a cardiac allograft who also did not experience organ rejection after treatment with pembrolizumab. Through smaller trials, retrospective analyses, case series and individual case reports, we are accumulating initial data on how these agents are tolerated by the aforementioned groups. Our survey of the literature has found more evidence of organ transplant rejection in patients treated with PD-1 inhibitors than those treated with inhibitors of cytotoxic T-lymphocyte antigen 4. Patients with chronic viral infections, especially hepatitis C, seem to have little to no risk of treatment-related increase in serum RNA levels. The literature contains few documented cases of devastating exacerbations of pre-existing autoimmune disease during treatment with ICIs, and flares seem to be easily controlled by immunosuppression in the vast majority of cases. Last, several cases allude to a promising role for disease-specific antibodies and other serum biomarkers in identifying patients at high risk of developing certain immune-related adverse events, detecting subclinical immune-related adverse event onset, and monitoring treatment response to immunosuppressive therapy in patients treated with ICIs. Though these excluded populations have not been well studied in randomized placebo-controlled trials, we may be able to learn and derive hypotheses from the existing observational data in the literature.
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Affiliation(s)
- Michael J Grant
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.,Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Nicholas DeVito
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - April K S Salama
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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Au L, O'Reilly A, Larkin J. Anti-PD-1 monotherapy versus anti-PD1 plus anti-CTLA4 in advanced melanoma: how do we decide? Melanoma Manag 2018; 4:151-155. [PMID: 30190919 DOI: 10.2217/mmt-2017-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/26/2017] [Indexed: 12/12/2022] Open
Affiliation(s)
- Lewis Au
- The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | - Aine O'Reilly
- The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | - James Larkin
- The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
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29
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Wen X, Wang Y, Ding Y, Li D, Li J, Guo Y, Peng R, Zhao J, Zhang X, Zhang XS. Safety of immune checkpoint inhibitors in Chinese patients with melanoma. Melanoma Res 2018; 26:284-9. [PMID: 27116334 DOI: 10.1097/cmr.0000000000000256] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study aimed to determine the tolerability of Chinese melanoma patients, particularly those with hepatitis B virus (HBV) infection, to immune checkpoint inhibitor therapy. Patients with metastatic melanoma who received anti-cytotoxic T lymphocyte-associated antigen-4 antibody (ipilimumab) or anti-programmed death 1 antibody (pembrolizumab) therapy at our hospital between August 2012 and July 2015 were retrospectively reviewed. Adverse events were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0. Twenty-three patients with advanced melanoma were included; nine and 10 patients received infusions of ipilimumab and pembrolizumab, respectively, whereas four patients received concurrent ipilimumab and pembrolizumab therapy. There was no cessation of treatment because of agent-related adverse events in any patient. Immune-related adverse events were observed in 44% (4/9), 60% (6/10), 100% (4/4), and 61% (14/23) of patients receiving ipilimumab, pembrolizumab, concomitant ipilimumab and pembrolizumab, and any treatment, respectively. The most frequent immune-related adverse events were endocrine disorders (39%, 9/23), liver function abnormalities (22%, 5/23), and dermatological events (17%, 4/23). There were no gastrointestinal reactions. Toxicities were usually mild and easily managed; only 13% (3/23) of patients had grade 3 adverse events and none experienced grade 4 events or treatment-related death. No additional toxicity nor severe hepatotoxicity was observed in 11 patients who had previous HBV infection. The recommended anti-cytotoxic T lymphocyte-associated antigen-4 and anti-programmed death 1 antibody doses were well tolerated by Chinese patients. Thus, immune checkpoint inhibitors appear to be effective and safe in metastatic melanoma patients, including those with pre-existing HBV infection.
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Affiliation(s)
- Xizhi Wen
- State Key Laboratory of Oncology in South China, Biotherapy Center, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
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Festino L, Ascierto PA. Side Effects of Cancer Immunotherapy with Checkpoint Inhibitors. Oncoimmunology 2018. [DOI: 10.1007/978-3-319-62431-0_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Baik CS, Rubin EH, Forde PM, Mehnert JM, Collyar D, Butler MO, Dixon EL, Chow LQM. Immuno-oncology Clinical Trial Design: Limitations, Challenges, and Opportunities. Clin Cancer Res 2017; 23:4992-5002. [PMID: 28864727 PMCID: PMC5735832 DOI: 10.1158/1078-0432.ccr-16-3066] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/13/2017] [Accepted: 07/05/2017] [Indexed: 12/21/2022]
Abstract
Recent advances in immuno-oncology and regulatory approvals have been rapid and paradigm shifting in many difficult-to-treat malignancies. Despite immune checkpoint inhibitor therapy becoming the standard of care across multiple tumor types, there are many unanswered questions that need to be addressed before this therapeutic modality can be fully harnessed. Areas of limitations include treatment of patients not sufficiently represented in clinical trials, uncertainty of the optimal treatment dosing and duration, and lack of understanding regarding long-term immune related toxicities and atypical tumor responses. Patients such as those with autoimmune disease, chronic viral infections, limited performance status, and brain metastases were often excluded from initial trials due to concerns of safety. However, limited data suggest that some of these patients can benefit from therapy with manageable toxicities; thus, future studies should incorporate these patients to clearly define safety and efficacy. There are still controversies regarding the optimal dosing strategy that can vary from weight-based to flat dosing, with undefined treatment duration. Further elucidation of the optimal dosing approach and evaluation of predictive biomarkers should be incorporated in the design of future trials. Finally, there are long-term immune-mediated toxicities, atypical tumor responses such as pseudoprogression and endpoints unique to immuno-oncology that are not adequately captured by traditional trial designs; thus, novel study designs are needed. In this article, we discuss in detail the above challenges and propose needed areas of research for exploration and incorporation in the next generation of immuno-oncology clinical trials.
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Affiliation(s)
- Christina S Baik
- University of Washington/Seattle Cancer Care Alliance, Seattle, Washington.
| | - Eric H Rubin
- Merck Research Laboratories, North Wales, Pennsylvania
| | - Patrick M Forde
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Janice M Mehnert
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | | | | | | | - Laura Q M Chow
- University of Washington/Seattle Cancer Care Alliance, Seattle, Washington
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Check point inhibitors as therapies for infectious diseases. Curr Opin Immunol 2017; 48:61-67. [PMID: 28865357 DOI: 10.1016/j.coi.2017.07.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/19/2017] [Accepted: 07/21/2017] [Indexed: 01/16/2023]
Abstract
The recent successes of immune check point targeting therapies in treating cancer patients has driven a resurgence of interest in targeting these pathways in chronically infected patients. While still in early stages, basic and clinical data suggest that blockade of CTLA-4 and PD-1 can be beneficial in the treatment of chronic HIV, HBV, and HCV infection, as well as other chronic maladies. Furthermore, novel inhibitory receptors such as Tim-3, LAG-3, and TIGIT are the potential next wave of check points that can be manipulated for the treatment of chronic infection. Blockade of these pathways influences more than simply T cell responses, and may provide new therapeutic options for chronically infected patients.
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Pathogenesis, clinical manifestations and management of immune checkpoint inhibitors toxicity. TUMORI JOURNAL 2017; 103:405-421. [PMID: 28497847 DOI: 10.5301/tj.5000625] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors have emerged as an effective treatment for several tumor types and their use in clinical practice is expected to further increase in the immediate future. Although these agents are well tolerated, they are associated with a peculiar spectrum of toxicity, which is immune mediated and may potentially affect every organ. However, immune-related adverse events are mostly reversible if promptly diagnosed and adequately treated. Therefore, it is crucial that medical oncologists know how to diagnose and treat immune-related adverse events. This review focuses on the pathogenesis, clinical manifestations and management of immune-related toxicity of anti-CTLA-4 and anti-PD-1 antibodies.
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Jaberg-Bentele NF, Kunz M, Abuhammad S, Dummer R. Flare-Up of Rheumatoid Arthritis by Anti-CTLA-4 Antibody but Not by Anti-PD1 Therapy in a Patient with Metastatic Melanoma. Case Rep Dermatol 2017; 9:65-68. [PMID: 28611624 PMCID: PMC5465736 DOI: 10.1159/000454875] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/29/2016] [Indexed: 12/28/2022] Open
Abstract
A 47-year-old female patient with rheumatoid arthritis (RA) treated with methotrexate, was diagnosed with metastatic melanoma. After surgical removal of the tumor, the patient started treatment with ipilimumab while methotrexate was stopped. One week after initiation of ipilimumab, the patient developed typical symptoms of RA. Analgetic therapy was started. After 4 cycles of ipilimumab, melanoma progression was radiologically evident. The treatment plan was changed to pembrolizumab (anti-PD1 antibody), and the patient did not show active signs of RA anymore. Despite treatment with pembrolizumab, the patient died 4 months later due to tumor progression. The exact mechanism by which ipilimumab (anti-CTLA-4 antibody) provoked RA symptoms is still not fully understood. This subject needs more investigation, especially in an era in which immunotherapies are a standard therapy for patients with malignancy.
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Affiliation(s)
| | - Michael Kunz
- aDepartment of Dermatology, University Hospital of Zürich, Zurich, Switzerland
| | - Shatha Abuhammad
- bResearch Division, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Reinhard Dummer
- aDepartment of Dermatology, University Hospital of Zürich, Zurich, Switzerland
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Abstract
INTRODUCTION The treatment of melanoma is evolving rapidly over the past few years. Patients with BRAFv600 mutations can be treated with a combination of a BRAF-inhibitor and an MEK-inhibitor. Patients with BRAF wild-type tumors and BRAFv600 mutated tumors can be treated with immunotherapy i.e. check point inhibitors. AREAS COVERED We conducted a comprehensive review of the literature on the efficacy and predictive markers, safety, and pharmacoeconomics of ipilimumab in melanoma Expert commentary: Ipilimumab was the first check point inhibitor reaching the clinic, gaining FDA and EMA approval for metastatic melanoma in 2011. Ipilimumab was also approved by FDA in the adjuvant setting for patients with high risk, stage III melanoma. The anti-PD1 directed antibodies pembrolizumab and nivolumab are superior to single agent ipilimumab, which is no longer considered the standard first line treatment in metastatic melanoma. The addition ipilimumab to nivolumab is associated with a higher response rate and a better PFS, particularly in patients with PD-L1 negative tumors, albeit at the cost of a steep increase in grade 3-4 adverse event rate. Definitive survival data on this combination are pending and the selection of patients potentially requiring the combination and its pharmacoeconomic implications are to be elucidated.
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Affiliation(s)
- Pol Specenier
- a Oncology , Universitair Ziekenhuis Antwerpen , Edegem , Belgium
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Viganò M, Serra G, Casella G, Grossi G, Lampertico P. Reactivation of hepatitis B virus during targeted therapies for cancer and immune-mediated disorders. Expert Opin Biol Ther 2016; 16:917-26. [PMID: 27088278 DOI: 10.1080/14712598.2016.1177017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Targeted therapies have gained popularity in the treatment of several oncologic and immune-mediated diseases. Immunosuppression caused by these drugs has been associated to reactivation of hepatitis B virus (HBV) in both hepatitis B surface antigen (HBsAg) positive patients (overt infection) and HBsAg negative/anti-hepatitis B core antigen (anti-HBc) positive carriers (resolved infection), leading to premature discontinuation of therapy and potentially fatal hepatitis. AREAS COVERED This review summarizes the evidence of HBV reactivation in patients with overt or resolved HBV infection undergoing targeted therapies for cancer or immune-mediated disorders, providing recommendations for the management of these patients. EXPERT OPINION The risk of HBV reactivation relies on the immunosuppressive potency and duration of these therapies, the underlying disease and the virological patient's profile. However, HBV reactivation is preventable by screening for HBV markers in all patients scheduled to receive targeted therapies, assessing the virological profile and patient's clinical state, followed by appropriate antiviral treatment or prophylaxis in those patients at high risk of HBV reactivation. Close monitoring of HBV carriers at low risk of reactivation is warranted with the aim to start antiviral therapy as soon as HBV reactivates.
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Affiliation(s)
- Mauro Viganò
- a Hepatology Unit, Ospedale San Giuseppe , Università di Milano , Milan , Italy
| | | | | | - Glenda Grossi
- c A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Università di Milano , Milan , Italy
| | - Pietro Lampertico
- c A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Università di Milano , Milan , Italy
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Hato T, Zhu AX, Duda DG. Rationally combining anti-VEGF therapy with checkpoint inhibitors in hepatocellular carcinoma. Immunotherapy 2016; 8:299-313. [PMID: 26865127 DOI: 10.2217/imt.15.126] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a fatal disease with rising incidence in the world. For advanced HCC, sorafenib, a multikinase inhibitor, is the only systemic therapy with proven survival benefits. Sorafenib is a pan-VEGF receptor inhibitor, and thus many studies have focused its antivascular effects. But VEGF also acts as an immunosuppressive molecule. VEGF can inhibit maturation of dendritic cells, promote immune suppressive cell infiltration and enhance immune checkpoint molecules expression. On the other hand, potent VEGF inhibition may increase tumor hypoxia, which could hinder antitumor immunity or immunotherapy. Thus, achieving synergy when combining anti-VEGF therapy with immunotherapy may require proper polarization of the tumor microenvironment by dose titration or combination with other immunomodulating agents.
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Affiliation(s)
- Tai Hato
- Edwin L. Steele Laboratories, Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.,Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Andrew X Zhu
- Hematology/Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA 02114, USA
| | - Dan G Duda
- Edwin L. Steele Laboratories, Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Importance of including patients with comorbidities in clinical trials. Lancet Oncol 2016; 17:17-8. [DOI: 10.1016/s1470-2045(15)00452-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/19/2015] [Accepted: 10/19/2015] [Indexed: 01/18/2023]
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Champiat S, Lambotte O, Barreau E, Belkhir R, Berdelou A, Carbonnel F, Cauquil C, Chanson P, Collins M, Durrbach A, Ederhy S, Feuillet S, François H, Lazarovici J, Le Pavec J, De Martin E, Mateus C, Michot JM, Samuel D, Soria JC, Robert C, Eggermont A, Marabelle A. Management of immune checkpoint blockade dysimmune toxicities: a collaborative position paper. Ann Oncol 2015; 27:559-74. [PMID: 26715621 DOI: 10.1093/annonc/mdv623] [Citation(s) in RCA: 607] [Impact Index Per Article: 67.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/18/2015] [Indexed: 12/13/2022] Open
Abstract
Monoclonal antibodies targeted against the immune checkpoint molecules CTLA-4 and PD-1 have recently obtained approval for the treatment of metastatic melanoma and advanced/refractory non small-cell lung cancers. Therefore, their use will not be limited anymore to selected hospitals involved in clinical trials. Indeed, they will be routinely prescribed in many cancer centers across the world. Besides their efficacy profile, these immune targeted agents also generate immune-related adverse events (irAEs). This new family of dysimmune toxicities remains largely unknown to the broad oncology community. Although severe irAEs remain rare (∼10% of cases under monotherapy), they can become life-threatening if not anticipated and managed appropriately. Over the last 5 years, Gustave Roussy has accumulated a significant experience in the prescription of immune checkpoint blockade (ICB) antibodies and the management of their toxicities. Together with the collaboration of Gustave Roussy's network of organ specialists with expertise in irAEs, we propose here some practical guidelines for the oncologist to help in the clinical care of patients under ICB immunotherapy.
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Affiliation(s)
- S Champiat
- Department of Drug Development (DITEP), Gustave Roussy Inserm U981, Univ. Paris-Sud, Université Paris-Saclay, Villejuif
| | - O Lambotte
- Department of Internal Medicine and Clinical Immunology, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Bicêtre, Le Kremlin Bicêtre Université Paris Sud 11, Le Kremlin-Bicêtre CEA, DSV/iMETI, Division of Immuno-Virology, IDMIT, Fontenay-aux-Roses INSERM, U1184, Center for Immunology of Viral Infections and Autoimmune Diseases, Le Kremlin-Bicêtre
| | - E Barreau
- Department of Ophthalmology, Hôpital Universitaire Bicêtre, Le Kremlin Bicêtre
| | - R Belkhir
- Department of Rheumatology, Hôpitaux Universitaires Paris-Sud, Hôpital Bicêtre, AP-HP, Le Kremlin Bicêtre
| | - A Berdelou
- Department of Nuclear Medicine and Endocrine Tumors, Gustave Roussy, Univ. Paris-Sud, Université Paris-Saclay, Villejuif
| | - F Carbonnel
- Gastroenterology Unit, Université Paris-Sud, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Sud, Le Kremlin Bicêtre
| | - C Cauquil
- Division of Adult Neurology, Hôpital Universitaire Bicêtre, Le Kremlin Bicêtre
| | - P Chanson
- Faculty of Medicine, Université Paris-Saclay, Univ Paris-Sud, Paris-Sud, UMR-S1185, Le Kremlin Bicêtre Unit of Endocrinology and reproductive Health, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Le Kremlin Bicêtre Unit of Gastroenterology, Institut National de la Santé et de la Recherche Médicale U1185 (P.C.), Le Kremlin Bicêtre
| | - M Collins
- Gastroenterology Unit, Université Paris-Sud, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Sud, Le Kremlin Bicêtre
| | - A Durrbach
- Department of Nephrology and Transplantation, Bicêtre Hospital, Paris Saclay University, INSERM 1197, Le Kremlin Bicêtre
| | - S Ederhy
- Department of Cardiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University [UPMC], Paris-Sorbonne, Paris
| | - S Feuillet
- Department of Thoracic and cardiovascular, and transplantation cardio-pulmonary, Hôpital Marie-Lannelongue, Le Plessis-Robinson Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre
| | - H François
- Department of Nephrology and Transplantation, Bicêtre Hospital, Paris Saclay University, INSERM 1197, Le Kremlin Bicêtre
| | - J Lazarovici
- Hematology Unit, Department of Medical Oncology, Gustave Roussy, Univ. Paris-Sud, Université Paris-Saclay, Villejuif
| | - J Le Pavec
- Department of Thoracic and cardiovascular, and transplantation cardio-pulmonary, Hôpital Marie-Lannelongue, Le Plessis-Robinson Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre UMR_S 999, Univ. Paris-Sud; INSERM; Hôpital Marie Lannelongue, Le Plessis Robinson
| | - E De Martin
- Centre Hépato-Biliaire, AP-HP, Hôpital Universitaire Paul Brousse Inserm U1193
| | - C Mateus
- Dermatology Unit, Department of Medical Oncology, Gustave Roussy, Univ. Paris-Sud, Université Paris-Saclay, Villejuif
| | - J-M Michot
- Department of Drug Development (DITEP), Gustave Roussy
| | - D Samuel
- Centre Hépato-Biliaire, AP-HP, Hôpital Universitaire Paul Brousse Inserm U1193
| | - J-C Soria
- Department of Drug Development (DITEP), Gustave Roussy Inserm U981, Univ. Paris-Sud, Université Paris-Saclay, Villejuif
| | - C Robert
- Inserm U981, Univ. Paris-Sud, Université Paris-Saclay, Villejuif Dermatology Unit, Department of Medical Oncology, Gustave Roussy, Univ. Paris-Sud, Université Paris-Saclay, Villejuif
| | | | - A Marabelle
- Department of Drug Development (DITEP), Gustave Roussy Gustave Roussy Cancer Campus, Villejuif Inserm 1015, Univ. Paris-Sud, Université Paris-Saclay, Villejuif, France
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Harding JJ, El Dika I, Abou-Alfa GK. Immunotherapy in hepatocellular carcinoma: Primed to make a difference? Cancer 2015; 122:367-77. [PMID: 26540029 DOI: 10.1002/cncr.29769] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/04/2015] [Accepted: 09/17/2015] [Indexed: 12/14/2022]
Abstract
Advanced hepatocellular carcinoma (HCC) carries a dismal prognosis and the current treatment is limited to sorafenib, an agent with modest benefit. Preclinical data have indicated that several immunologic mechanisms are at play to promote HCC development and growth while impairing effective antitumor immune surveillance. Several novel approaches geared toward manipulating the immune response to HCC have suggested a therapeutic benefit in early-stage clinical trials, indicating a real potential to augment tumor-specific immunity and improve outcomes in patients with this disease. In the current study, the authors reviewed the barriers to an effective immune response against HCC and contemporary clinical investigations that may be "primed" to alter the natural history of HCC.
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Affiliation(s)
- James J Harding
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
| | - Imane El Dika
- Internal Medicine/Hematology and Oncology, American University of Beirut, Beirut, Lebanon
| | - Ghassan K Abou-Alfa
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
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Abdel-Rahman O, ElHalawani H, Fouad M. Risk of elevated transaminases in cancer patients treated with immune checkpoint inhibitors: a meta-analysis. Expert Opin Drug Saf 2015; 14:1507-18. [PMID: 26394770 DOI: 10.1517/14740338.2015.1085969] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND This meta-analysis has been conducted to determine the risk of elevated transaminases associated with immune checkpoint inhibitors use in patients with cancer. METHODS Studies eligible for our analysis included randomized Phase II and III trials of patients with cancer on ipilimumab, nivolumab, pembrolizumab, tremelimumab and pidilizumab, which describe events of elevated transaminases [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)]. RESULTS Initial database search revealed 210 relevant citations. After excluding noneligible studies, 10 trials were considered eligible for the quantitative synthesis. The RR of all-grade elevated ALT and AST was 2.36 (95% CI 1.20-4.66; p = 0.01) and 1.53 (95% CI 0.73-3.22; p = 0.26), respectively, whereas for high-grade elevated ALT and AST, it was 11.27 (95% CI 5.38-23.63; p < 0.0001) and 4.9 (95% CI 2.97-8.09; p < 0.0001), respectively. CONCLUSIONS Our study has shown that the use of immune checkpoint inhibitors has a causal relationship to an increased risk of high-grade elevated ALT and AST. Clinicians using these agents should be attentive of this risk.
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Affiliation(s)
- Omar Abdel-Rahman
- a 1 Ain Shams University, Clinical Oncology Department , Cairo, Egypt +33028656 ;
| | - Hesham ElHalawani
- a 1 Ain Shams University, Clinical Oncology Department , Cairo, Egypt +33028656 ;
| | - Mona Fouad
- b 2 Ain Shams University, Medical Microbiology and Immunology Department , Cairo, Egypt
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Abstract
The toxicities of immunotherapy for cancer are as diverse as the type of treatments that have been devised. These range from cytokine therapies that induce capillary leakage to vaccines associated with low levels of autoimmunity to cell therapies that can induce damaging cross-reactivity with normal tissue to checkpoint protein inhibitors that induce immune-related adverse events that are autoinflammatory in nature. The thread that ties these toxicities together is their mechanism-based immune nature and the T-cell-mediated adverse events seen. The basis for the majority of these adverse events is a hyperactivated T-cell response with reactivity directed against normal tissue, resulting in the generation of high levels of CD4 T-helper cell cytokines or increased migration of cytolytic CD8 T cells within normal tissues. The T-cell immune response is not tissue specific and may reflect a diffuse expansion of the T-cell repertoire that induces cross-reactivity with normal tissue, effectively breaking tolerance that is active with cytokines, vaccines, and checkpoint protein inhibitors and passive in the case of adoptive cell therapy. Cytokines seem to generate diffuse and nonspecific T-cell reactivity, whereas checkpoint protein inhibition, vaccines, and adoptive cell therapy seem to activate more specific T cells that interact directly with normal tissues, potentially causing specific organ damage. In this review, we summarize the toxicities that are unique to immunotherapies, emphasizing the need to familiarize the oncology practitioner with the spectrum of adverse events seen with newly approved and emerging modalities.
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Affiliation(s)
- Jeffrey S Weber
- Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; James C. Yang, National Cancer Institute, Bethesda, MD; Michael B. Atkins, Lombardi Cancer Center, Georgetown University, Washington, DC; and Mary L. Disis, The Fred Hutchinson Cancer Center, University of Washington, Seattle, WA.
| | - James C Yang
- Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; James C. Yang, National Cancer Institute, Bethesda, MD; Michael B. Atkins, Lombardi Cancer Center, Georgetown University, Washington, DC; and Mary L. Disis, The Fred Hutchinson Cancer Center, University of Washington, Seattle, WA
| | - Michael B Atkins
- Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; James C. Yang, National Cancer Institute, Bethesda, MD; Michael B. Atkins, Lombardi Cancer Center, Georgetown University, Washington, DC; and Mary L. Disis, The Fred Hutchinson Cancer Center, University of Washington, Seattle, WA
| | - Mary L Disis
- Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; James C. Yang, National Cancer Institute, Bethesda, MD; Michael B. Atkins, Lombardi Cancer Center, Georgetown University, Washington, DC; and Mary L. Disis, The Fred Hutchinson Cancer Center, University of Washington, Seattle, WA
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