Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group

Latent profile analysis of self-management and its association with quality of life differences in patients with cancer treated with immune checkpoint inhibitors

Objective

This study aimed to explore latent profiles of self-management ability in patients with cancer treated with immune checkpoint inhibitors, analyze each subgroup's characteristics, and determine the relationship between self-management and quality of life.

Methods

This cross-sectional study included 393 patients treated with immune checkpoint inhibitors. The participants completed questionnaires containing sociodemographic information, the Functional Assessment of Cancer Therapy-Immune Checkpoint Modulator (FACT-ICM), the Cancer Patient Self-management Evaluation Scale, and the Medical Coping Modes Questionnaire. Latent profile analysis was used to examine potential latent groups of self-management. Multivariate logistic regression was used to analyze the sociodemographic variables in each profile. Kruskal-Wallis H-rank sum test was used to explore the relationships between self-management profiles and quality of life.

Results

The self-management abilities of the patients treated with immune checkpoint inhibitors were grouped into three latent profiles: "low self-management" (16.8%), "average self-management-avoidance of information" (44.3%), and "high self-management" (38.9%). The coping modes, educational levels, medical insurances, age, monthly family income per capita, and communication styles with health care professionals post-discharge significantly influenced the distribution of self-management. There were significant differences in the FACT-ICM scores across all three groups, except for the emotional well-being dimension.

Conclusions

The patients with cancer treated with immune checkpoint inhibitors exhibit three distinct self-management profiles. To enhance patients' quality of life, healthcare professionals should develop targeted self-management strategies focusing on information management and communication between patients and healthcare providers.

Rechallenge with immune-checkpoint inhibitors in patients with advanced-stage lung cancer

Lung cancer remains the leading cause of cancer-related mortality globally, with many patients diagnosed with advanced-stage disease. Treatment in this setting relies on systemic therapies, including chemotherapy, targeted therapy and immunotherapy. Immune-checkpoint inhibitors (ICIs), which promote or restore antitumour immunity by inhibiting immunosuppressive signalling pathways, are currently the most widely used immunotherapies in these patients. However, immune-related adverse events (irAEs) or disease progression often necessitate discontinuation of these agents, leaving many patients with limited subsequent treatment options. In this scenario, ICI rechallenge has emerged as a potential strategy. Despite this potential, evidence for ICI rechallenge after either disease progression or irAEs in patients with non-small-cell lung cancer is limited and evidence for those with small cell lung cancer seems to be non-existent. In this Review, we provide a comprehensive overview of the available data on ICI rechallenge in the context of both disease progression and irAEs, including a summary of current guidance on clinical management and detailed discussions of safety and efficacy. We also highlight important unanswered questions in an attempt to guide future research in this area.

The Utility of Magnetic Resonance Imaging for Hypophysitis Secondary to Immune Checkpoint Inhibitor Use

OBJECTIVE

Immune checkpoint inhibitor (ICI) therapy is an efficacious cancer treatment, often resulting in autoimmune off-target effects. Magnetic resonance imaging (MRI) has been a recommended investigation for ICI-related hypophysitis. We sought to identify the frequency of identifiable MRI changes.

DESIGN

A retrospective case-control audit was performed of individuals who received one or more ICI between January 2018 and December 2023 at a single tertiary referral centre in Melbourne, Australia.

PATIENTS

Individuals requiring hormone supplementation were screened for hypophysitis. A randomly selected control group receiving ICI demonstrated normal pituitary function at the time of MRI.

MEASUREMENTS AND RESULTS

Fifty-four (6.9%) of 778 individuals who received ICI therapy were diagnosed with ICI-related hypophysitis. 43 had an MRI examining the pituitary gland within 2 months. Four (9.3%) had initial reporting consistent with hypophysitis. Upon re-examination by an MRI-Fellowship trained radiologist, a further 6 (total 10, 23%) had acute hypophysitis changes. Among the control group, 45 of 46 individuals had an MRI within 2 months of normal pituitary biochemistry. All initial MRI reports were normal, but upon review 1 (2.2%) had acute hypophysitis abnormalities, with a significant difference between groups (10/43 vs 1/45, p = 0.003). Within the control group, a further 10 (22%) individuals had an atrophic pituitary and/or empty sella. No other significant pituitary pathology, including pituitary metastasis, was identified.

CONCLUSIONS

Although changes were observed in a minority of patients with hypophysitis, MRI provides minimal additional clinically meaningful information, so it could be reserved for atypical cases or those with persisting symptoms despite adequate supplementation.

Co-Occurrence of Hypophysitis and Thyroiditis Induced by PD-L1 Inhibitor Avelumab: Clinical Insights

Various endocrinopathies have been described in patients with malignancies who are receiving treatment with immune checkpoint inhibitors (ICIs). We present the case of a patient who was hospitalized with an acute alteration in mental status and was referred to the endocrinology service for evaluation of abnormal thyroid function tests. Subsequent investigation revealed the presence of acute adrenal insufficiency, which was successfully managed with steroid replacement therapy. This case highlights a unique simultaneous presentation of thyrotoxicosis due to thyroiditis and adrenal insufficiency due to hypophysitis in a patient treated with ICI avelumab for 5 months.

Dermatologic toxicities related to cancer immunotherapy

Immunotherapy has revolutionized cancer treatment, offering significant survival superiority for advanced malignancies. However, immunotherapy is associated with various immune-related adverse events, one of the most common of them being dermatologic toxicities. Previous studies have reported dermatologic adverse events in almost half of the cancer patients undergoing immunotherapy. The spectrum of dermatologic toxicities ranges from mild, self-limiting reactions to severe, life-threatening conditions, and includes maculopapular rash, pruritus, vitiligo-like depigmentation, psoriasiform eruption, lichenoid eruption, bullae, photosensitivity, hair loss, nail changes, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The management strategies are based on personalized treatment plans, multidisciplinary approaches, and timely therapeutic interventions aimed at addressing dermatologic toxicities while preserving immunotherapy efficacy. Based on the latest findings, this paper offers a novel perspective and provides an evidence-based review of the pathogenesis, manifestations, incidence, grading, clinical management, and prognostic significance of these toxicities, underlining the importance of balancing the efficacy of immunotherapy with timely and proactive management of their dermatological toxicities to enhance patient outcomes and quality of life.

Unraveling the mechanisms of irAEs in endometrial cancer immunotherapy: insights from FAERS and scRNA-seq data

Endometrial cancer (EC) is one of the most common malignancies in women. In recent years, immunotherapy has gradually become a significant treatment option. However, the mechanisms underlying immune checkpoint inhibitor (ICI)-related Adverse Events (AEs) remain poorly understood, posing significant challenges for optimizing clinical treatment strategies. This study aims to integrate the FAERS database and single-cell transcriptomic data to investigate potential mechanisms underlying PD-1 inhibitor-related AEs in EC immunotherapy, with a focus on exploring the PD-1-associated cell communication network and its potential compensatory activation pathways. Data related to AEs were extracted from the FAERS database. Disproportionality analyses, including Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (MGPS), were used to quantify signals of immune-related AEs (irAEs) associated with ICIs. We compared the occurrence timing and characteristics of AEs across different drugs. Subsequently, scRNA-seq was performed to analyze the tumor microenvironment of EC, focusing on PD-1-high expressing cell populations. Cell Communication was analyzed and key receptor-ligand pairs were identified. From Q1 2004 to Q3 2024, 21,838,627 drug-related reports were retrieved from FAERS, including 2,202 related to ICIs. ICI-associated irAEs involved 26 organ systems, with general disorders, gastrointestinal disorders, and injury/poisoning as the top System Organ Class (SOC). Fatigue, product use issues, and diarrhea were the most reported Preferred Terms (PTs). PD-1 inhibitors were associated with faster onset of AEs compared to PD-L1 inhibitors and Weibull modeling indicated an early failure-type AE pattern for both treatments. Single-cell analysis further demonstrated that PD-1 was highly expressed in CD8 + cytotoxic T cells and Tfh cells, which communicated with other cells within the tumor microenvironment through key receptor-ligand pairs such as CXCL12-CXCR4 and CXCL16-CXCR6. These findings suggested that PD-1 inhibitors may induce AEs through compensatory activation of the CXCR4 and CXCR6 pathways. This study suggested that PD-1 inhibitors may contribute to irAEs in EC, potentially through compensatory activation of the CXCR4 and CXCR6 pathways. By integrating FAERS and scRNA-seq data, key receptor-ligand interactions were identified, providing preliminary insights that could inform future efforts to optimize immunotherapy efficacy and mitigate AEs. However, further validation through clinical studies and mechanistic research is needed to confirm these findings.

Programmed death-ligand 1 tumor proportion score in predicting the safety and efficacy of PD-1/PD-L1 antibody-based therapy in patients with advanced non-small cell lung cancer: A retrospective, multicenter, observational study

BACKGROUND

This study aimed to investigate the safety and efficacy of programmed cell death-1 (PD-1)/programmed cell death-ligand 1 (PD-L1) antibody-based therapy in treating patients with advanced non-small cell lung cancer (NSCLC) according to different PD-L1 expression statuses in a real-world setting.

METHODS

This retrospective, multicenter, observational study enrolled adult patients who received PD-1/PD-L1 antibody-based therapy in China and met the following criteria: (1) had pathologically confirmed, unresectable stage III-IV NSCLC; (2) had a baseline PD-L1 tumor proportion score (TPS); and (3) had confirmed efficacy evaluation results after PD-1/PD-L1 treatment. Logistic regression, Kaplan-Meier analysis, and Cox regression were used to assess the progression-free survival (PFS), overall survival (OS), and immune-related adverse events (irAEs) as appropriate.

RESULTS

A total of 409 patients, 65.0% (n = 266) with a positive PD-L1 TPS (≥1%) and 32.8% (n = 134) with PD-L1 TPS ≥50%, were included in this study. Cox regression confirmed that patients with a PD-L1 TPS ≥1% had significantly improved PFS (hazard ratio [HR] 0.747, 95% confidence interval [CI] 0.573-0.975, P = 0.032). A total of 160 (39.1%) patients experienced 206 irAEs, and 27 (6.6%) patients experienced 31 grade 3-5 irAEs. The organs most frequently associated with irAEs were the skin (52/409, 12.7%), thyroid (40/409, 9.8%), and lung (34/409, 8.3%). Multivariate logistic regression revealed that a PD-L1 TPS ≥1% (odds ratio [OR] 1.713, 95% CI 1.054-2.784, P = 0.030) was an independent risk factor for irAEs. Other risk factors for irAEs included pretreatment absolute lymphocyte count >2.5 × 109/L (OR 3.772, 95% CI 1.377-10.329, P = 0.010) and pretreatment absolute eosinophil count >0.2 × 109/L (OR 2.006, 95% CI 1.219-3.302, P = 0.006). Moreover, patients who developed irAEs demonstrated improved PFS (13.7 months vs. 8.4 months, P <0.001) and OS (28.0 months vs. 18.0 months, P = 0.007) compared with patients without irAEs.

CONCLUSIONS

A positive PD-L1 TPS (≥1%) was associated with improved PFS and an increased risk of irAEs in a real-world setting. The onset of irAEs was associated with improved PFS and OS in patients with advanced NSCLC receiving PD-1/PD-L1-based therapy.

Cardiological adverse events in hepatocellular carcinoma patients receiving immunotherapy: Influence of comorbidities and clinical outcomes

INTRODUCTION

Immunotherapy-based combinations have revolutionized the first-line treatment for advanced hepatocellular carcinoma (HCC), improving overall survival (OS). However, these therapies are associated with adverse events (AEs), particularly cardiological complications and major adverse cardiovascular events (MACE), which may adversely affect outcomes. The influence of comorbid conditions such as arterial hypertension (AHT) and type 2 diabetes mellitus (T2DM) on the incidence and prognosis of cardiological AEs in HCC patients remains understudied.

METHODS

This retrospective study included 109 HCC patients treated with atezolizumab-bevacizumab, tremelimumab-durvalumab, or durvalumab as first-line therapy at two Spanish medical centers from 2017-2023. Patients were stratified by comorbidities, AE incidence, and cardiological risk (CARDIOSOR scale). The primary endpoints were the incidence of treatment-modifying AEs and MACE, and their association with survival.

RESULTS

Among the cohort, 50.5 % experienced AEs of special interest (AESI), with 34 % considered immune-related (irAE). MACE occurred in 7.3 % of patients, including myocarditis (3.7 %). The CARDIOSOR scale identified a higher risk of MACE in patients with AHT, T2DM, or both (OR: 5.07, p = 0.034). Early cardiological AEs were independently associated with worse OS (HR: 3.38, p = 0.04). Patients with both AHT and T2DM exhibited higher rates of MACE (16.7 %) and treatment discontinuation (25.9 %). The CARDIOSOR scale effectively stratified patients into high-risk groups, correlating with increased MACE rates and poor survival outcomes.

CONCLUSIONS

Comorbid conditions, particularly AHT and T2DM, amplify the risk of MACE and influence treatment discontinuation. The CARDIOSOR scale is a valuable tool for personalized risk assessment, guiding tailored therapeutic strategies. Integrating cardiovascular risk management into HCC care is crucial for optimizing both oncological and cardiovascular outcomes.

Roles of the gut microbiota in immune-related adverse events: mechanisms and therapeutic intervention

Immune checkpoint inhibitors (ICIs) constitute a major breakthrough in the field of cancer therapy; their use has resulted in improved outcomes across various tumour types. However, ICIs can cause a diverse range of immune-related adverse events (irAEs) that present a considerable challenge to the efficacy and safety of these treatments. The gut microbiota has been demonstrated to have a crucial role in modulating the tumour immune microenvironment and thus influences the effectiveness of ICIs. Accumulating evidence indicates that alterations in the composition and function of the gut microbiota are also associated with an increased risk of irAEs, particularly ICI-induced colitis. Indeed, these changes in the gut microbiota can contribute to the pathogenesis of irAEs. In this Review, we first summarize the current clinical challenges posed by irAEs. We then focus on reported correlations between alterations in the gut microbiota and irAEs, especially ICI-induced colitis, and postulate mechanisms by which these microbial changes influence the occurrence of irAEs. Finally, we highlight the potential value of gut microbial changes as biomarkers for predicting irAEs and discuss gut microbial interventions that might serve as new strategies for the management of irAEs, including faecal microbiota transplantation, probiotic, prebiotic and/or postbiotic supplements, and dietary modulations.

Haematological toxicities with immune checkpoint inhibitors in digestive system tumors: a systematic review and network meta-analysis of randomized controlled trials

This study aims to comprehensively evaluate the hematologic toxicity profiles, toxicity spectrum, and safety rankings of immune checkpoint inhibitors (ICIs) used for digestive system tumors. The PubMed, Cochrane Library, Web of Science, and Embase databases were systematically searched from inception to August 2024 to identify randomized controlled trials (RCTs). The primary outcome was anemia, while secondary outcomes included neutropenia, neutrophil count decreased, thrombocytopenia, platelet count decreased, leukopenia, white blood cell (WBC) count decreased, lymphocyte count decreased, and febrile neutropenia (FN). Subgroup analyses were performed based on tumor type, country category, study phase, ICI regimen, control group, chemotherapy regimen, ICI plus different chemotherapy regimens. Two reviewers independently selected the studies, extracted data according to pre-specified criteria, and assessed the risk of bias using the Cochrane Collaboration risk of bias tool. RevMan 5.4 software was utilized to visualize the risk of bias assessments. Stata 16.0 was used to conduct network meta-analysis, sensitivity analysis and meta-regression. 25 phase II and III RCTs (n = 15216) were included. The general safety of ICIs ranked from high to low for grade 1-5 anemia were as follows: avelumab, nivolumab, pembrolizumab, sintilimab, camrelizumab, and tislelizumab. For grade 3-5 anemia, the general safety profile of the ICIs were as follows, from highest to lowest: avelumab, nivolumab, pembrolizumab, sintilimab, and camrelizumab. Compared to chemotherapy, treatment-related hematologic toxicities with ICIs occurred primarily in grade 1-5 anemia, neutropenia, thrombocytopenia, leukopenia, and WBC count decreased. Taking ICI monotherapy, nivolumab plus ipilimumab were generally safer than taking chemotherapy, one ICI drug with chemotherapy, or two ICI drugs with chemotherapy. In terms of grade 1-5 hematologic toxicities, tislelizumab had the highest risk of neutropenia and leukopenia; the primary treatment-adverse events (AEs) for sintilimab was neutrophil count decreased and WBC count decreased; the primary treatment-related AE associated with nivolumab was platelet count decreased; camrelizumab posed the highest risk for lymphocyte count decreased. In terms of grade 3-5 hematologic toxicities, pembrolizumab was predominantly linked to neutropenia; sintilimab showed the greatest risk for neutrophil count decreased, platelet count decreased, and lymphocyte count decreased; avelumab was most associated with WBC count decreased. FN primarily manifested as grade 3-5, with camrelizumab having the highest risk. Among agents used in gastric or gastroesophageal junction cancer, avelumab demonstrated the most favorable safety profile for anemia. Each treatment regimen has its unique safety profile. Early identification and management of ICI-related hematologic toxicities are essential in clinical practice.Systematic Review Registration: PROSPERO CRD42024571508.

Complex neural-immune interactions shape glioma immunotherapy

Rich neural-immune interactions in the central nervous system (CNS) shape its function and create a unique immunological microenvironment for immunotherapy in CNS malignancies. Far from the now-debunked concept of CNS "immune privilege," it is now understood that unique immunological niches and constant immune surveillance of the brain contribute in multifaceted ways to brain health and robustly influence immunotherapy approaches for CNS cancers. Challenges include immune-suppressive and neurotoxicity-promoting crosstalk between brain, immune, and tumor cells. Developing effective immunotherapies for cancers of the nervous system will require a deeper understanding of these neural-immune-malignant cell interactions. Here, we review progress and challenges in immunotherapy for gliomas of the brain and spinal cord in light of these unique neural-immune interactions and highlight future work needed to optimize promising immunotherapies for gliomas.

Impact of pneumonitis from radiotherapy combined with immune checkpoint inhibitors therapy on tumor progression and survival in patients with non-small cell lung cancer

Purpose

This study evaluates the impact of thoracic radiotherapy (TRT) combined with immune checkpoint inhibitors (ICIs) treatment-related pneumonitis on tumor progression and prognosis in patients with non-small cell lung cancer (NSCLC).

Methods

Data were collected retrospectively from NSCLC patients treated with TRT and ICIs between January 2019 and August 2023. Treatment-related pneumonitis (TRP) was assessed and graded using the Common Terminology Criteria for Adverse Events (CTCAE) and the Chinese Society of Clinical Oncology Guidelines for Managing Immunotherapy-Related Toxicities. Kaplan-Meier curves and log-rank tests examined associations between pneumonitis with local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS). COX regression identified prognostic factors in the pneumonitis group.

Results

Among 86 patients, 58 (67.4%) developed TRP, including 37.2% with grade 2 pneumonitis, and no grade ≥3 cases. 12 patients (14.0%) developed mixed radiation and ICIs pneumonitis. The pneumonitis group had significantly shorter DMFS (12.07 vs not reached, p = 0.028) and PFS (9.53 vs 14.27 months, p = 0.040), shorter LRFS compared to the non-pneumonitis group, but similar OS. High-grade pneumonitis correlated with worse outcomes, especially DMFS (p = 0.031), basically no differences among pneumonitis types. Multivariate COX analysis identified solitary pulmonary nodules or masses as independent negative prognostic factors for PFS, while higher MLD (mean lung dose) independently predicted reduced OS.

Conclusion

Pneumonitis resulting from TRT combined with ICIs was associated with shorter PFS but did not affect OS in NSCLC patients. Mixed pneumonitis did not worsen outcomes. Larger prospective studies are needed to validate these findings.

Mechanisms of autoimmune-mediated paraneoplastic syndromes: immune tolerance and disease pathogenesis

Paraneoplastic syndromes represent a clinically heterogeneous group of disorders that arise in cancer patients. Although their underlying mechanisms are only partly understood, immune or endocrine mechanisms are believed to play key roles. Autoimmune-mediated paraneoplastic syndromes (AMPS) are typically characterized by the presence of autoantibodies, making their identification important for both AMPS diagnosis and early cancer detection. This review synthesizes emerging insights into the pathogenesis of AMPS, with a particular focus on how genomic instability in cancer cells promotes immune recognition of altered self-proteins. Mechanisms such as ectopic expression, protein modifications (such as isoaspartylation), and gene amplifications can disrupt immune tolerance, leading to autoimmunity. Additionally, chronic inflammation and the formation of tertiary lymphoid structures within the tumor microenvironment contribute to both antitumor immunity and autoimmunity. Immune checkpoint inhibitors (ICIs), have revolutionized cancer treatment by enhancing antitumor immunity, but they can also induce immune-related adverse events (irAEs), some of which mimic AMPS. These irAEs highlight the critical roles of both humoral and cellular immunity in AMPS development. By exploring the relationships between ICI treatment, immune tolerance, and tumor-specific antigens, this review aims to clarify the mechanisms driving AMPS and their dual role in cancer control and immune-mediated disease. Bridging these knowledge gaps may inform the development of novel therapeutic strategies for managing AMPS and in optimizing the use of ICIs in cancer care.

Clinical characteristics, outcomes, and predictive modeling of patients diagnosed with immune checkpoint inhibitor therapy-related pneumonitis

PURPOSE

The aim of this study is to better characterize the clinical characteristics and outcomes of patients diagnosed with Immune checkpoint Inhibitor (ICI) pneumonitis and propose predictive models.

PATIENTS AND METHODS

Patients diagnosed with ICI pneumonitis at Mayo Clinic from 2014 to 2022 were studied. All cases were independently reviewed by our pulmonology specialist (A.E.) to confirm the appropriate diagnosis. The grading of pneumonitis was defined in accordance with ASCO guidelines (Schneider et al. in J Clin Oncol 39(36):4073-4126, 2021. https://doi.org/10.1200/JCO.21.01440 ). Predictive modeling was performed using gradient boosting machine learning technology, XGBoost (Chen in 1(4):1, 2015), to conduct binary classification and model reverse engineering using Shapley statistics (Lundberg and Lee in Adv Neural Inf Process Syst 30, 2017).

RESULTS

One hundred and seventy patients with ICI pneumonitis were included (median age 67; IQR 59, 75). Median overall survival was 2.3 years (95% CI: 1.8, NR). A higher grade of ICI pneumonitis was associated with inferior survival (HR 5.85, 95% CI: 2.27, 15.09; p < 0.001). Patients who were rechallenged with immunotherapy had significantly improved hazard of survival compared to patients not rechallenged (HR 0.37, 95% CI: 0.21, 0.68; p = 0.001). Risk of death from ICI pneumonitis prior to starting immunotherapy was modeled with an area under the curve of the receiver operator characteristic (AUC-ROC) of 0.79 with the most contributory features including peripheral blood lymphocyte count, oxygen dependence, pulmonary function testing, and PD-L1 expression.

CONCLUSION

The presentation of ICI pneumonitis is highly variable, and outcomes are dependent on severity, but favor grade 2 disease when patients are rechallenged with immunotherapy. However, using commonly available clinical data, we can accurately identify patients at high risk of death from ICI pneumonitis. Further effort is needed to produce clinical models able to provide clinician decision support when evaluating patients with ICI toxicities and considering ICI rechallenge.

Management of immune-related myocarditis, myositis and myasthenia gravis (MMM) overlap syndrome: a single institution case series and literature review

Background

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of various malignancies, particularly melanoma. However, immune-related adverse events (irAEs) pose significant challenges, particularly in cases of severe toxicity syndromes. One such life-threatening irAE is the myocarditis, myositis, and myasthenia gravis (MMM) overlap syndrome, which occurs in less than 1% of patients but has in-hospital mortality rates ranging from 40 to 60%. Due to its rarity and complexity, early recognition and a multidisciplinary approach are critical to improving outcomes.

Methods

We present a single-institution case series of four patients diagnosed with MMM overlap syndrome following ICI therapy. Clinical presentation, laboratory findings, imaging, and electrophysiological tests were analyzed to confirm the diagnosis. Therapeutic interventions-including corticosteroids, intravenous immunoglobulins (IVIG), plasma exchange (PLEX), tocilizumab, and rituximab- were evaluated in terms of efficacy and clinical outcomes.

Results

The onset of MMM syndrome varied from 2 to 4 weeks after initiating ICI therapy. Patients presented with rapidly progressive symptoms, including ptosis, bulbar dysfunction, respiratory distress, myopathy, and cardiac conduction abnormalities. Immunosuppressive therapy with high-dose corticosteroids was initiated in all cases. Additional immunomodulatory treatments (IVIG, tocilizumab, PLEX, and rituximab) were administered based on clinical deterioration and autoimmune profile. Two patients achieved complete recovery, one remains on maintenance immunosuppression, and one died due to respiratory failure despite aggressive treatment.

Conclusion

MMM overlap syndrome is a severe and often fatal irAE associated with ICI therapy. Early identification, aggressive immunosuppressive treatment, and individualized therapeutic strategies are essential to optimize patient outcomes. Further research is needed to refine diagnostic criteria, identify predictive biomarkers, and establish standardized treatment protocols.

Sarcoid-Like Reaction (SLR) Associated With Immune Checkpoint Inhibitors in Metastatic Renal Cell Carcinoma

Introduction

Immune checkpoint inhibitors (ICIs) are useful in the treatment of metastatic renal cell carcinoma. ICIs have been associated with a variety of immune-related adverse events (irAEs), one of which is a sarcoid-like reaction (SLR). SLR is often difficult to distinguish from cancer progression.

Case Presentation

The patient is a 71-year-old woman. She underwent laparoscopic nephrectomy after 4 courses of ipilimumab + nivolumab therapy for clear cell renal cell carcinoma with femoral bone metastasis. In the pathological examination, in addition to tumor-infiltrating lymphocytes, numerous non-caseating epithelioid cell granulomas were found in the tumor. The occurrence of non-caseating epithelioid cell granuloma in a patient who did not meet the diagnostic criteria for systemic sarcoidosis was considered SLR due to ICI.

Conclusions

We report the first case of a patient who underwent surgery for metastatic renal cell carcinoma after treatment with ICI and who was pathologically diagnosed with SLR in the kidney.

Ocular Immune-Related Adverse Events Associated with PD-1 Inhibitors: From Molecular Mechanisms to Clinical Management

Purpose: To help ophthalmologists and oncologists better understand the ocular irAEs secondary to PD-1 inhibitors , enabling early detection and management of ocular complications.Methods: We reviewed case reports and related literatures on ocular irAEs secondary to PD-1 inhibitors in PubMed, including a total of 70 case reports, summarizing and analyzing the specific conditions of these patients.Results: The most common malignant tumors were melanoma (n = 41; 58.6%) and lung cancer (n = 13; 18.6%). The main PD-1 inhibitors used were pembrolizumab (n = 38; 54.3%) and nivolumab (n = 28; 40%). They may result in various ocular complications, with the most common being uveitis (n = 35; 50%) and myasthenia gravis (n = 13; 18.57%). Adverse events concerning the cornea and the retina were reported in 8 cases each (11.43%). Neuro-ophthalmic adverse events were reported in 6 cases (8.57%). Most of these toxicities responded to topical and systemic steroids. Severe manifestations, however, may require temporary or permanent cessation of PD-1 inhibitors treatment.Conclusions: With the increasing use of PD-1 inhibitors, ophthalmologists need to remain sensitive to the clinical manifestations of adverse events to ensure timely diagnosis and management. To improve their quality of life and reduce mortality, oncologists and ophthalmologists should maintain close cooperation and implement multi-disciplinary treatment.

Prevalence of symptomatic toxicities for novel therapies in adult oncology trials: a scoping review

BACKGROUND

Patients' self-report of their symptoms can provide important data for the evaluation of treatment benefit and tolerability of oncology drugs. Contemporary treatment approaches, including immunotherapy and molecular targeted therapies, have unique toxicities based on their novel mechanisms of action. This scoping review aimed to summarize evidence from existing reviews and clinical practice guidelines to examine the type and prevalence of toxicities including symptomatic adverse events (sympAEs) for adult cancer patients to inform clinical care and therapeutic trials.

METHODS

A systematic search of PubMed, Web of Science, and Embase was performed using predefined eligibility criteria. Thirty-one literature reviews and 3 clinical practice guidelines met inclusion criteria and were selected for review and data abstraction.

RESULTS

Findings from this scoping review demonstrated several leading sympAEs that were reported across immunotherapy and targeted therapy drugs, including fatigue, diarrhea, and rash. In addition to these more prevalent sympAEs, there were some less frequently reported class-specific sympAEs, which had potential for significant harm or disability to the patient if not properly identified and treated. Many studies reported toxicities as AEs or syndromes solely using data reported by clinicians without additional self-report from patients.

CONCLUSION

We identified several core sympAEs experienced by patients participating in oncology trials using immunotherapy and targeted therapy agents, which has implications for future trial design and drug labeling. Future cancer trials should assess patient-reported sympAEs based on the identified drug mechanism to inform the tolerability of these newer agents and enhance patient safety during trial participation and clinical care.

Clinical practice guidelines for perioperative multimodality treatment of non-small cell lung cancer

BACKGROUND

Lung cancer is currently the most prevalent malignancy and the leading cause of cancer deaths worldwide. Although the early stage non-small cell lung cancer (NSCLC) presents a relatively good prognosis, a considerable number of lung cancer cases are still detected and diagnosed at locally advanced or late stages. Surgical treatment combined with perioperative multimodality treatment is the mainstay of treatment for locally advanced NSCLC and has been shown to improve patient survival. Following the standard methods of neoadjuvant therapy, perioperative management, postoperative adjuvant therapy, and other therapeutic strategies are important for improving patients' prognosis and quality of life. However, controversies remain over the perioperative management of NSCLC and presently consensus and standardized guidelines are lacking for addressing critical clinical issues in multimodality treatment.

METHODS

The working group consisted of 91 multidisciplinary experts from thoracic surgery, medical oncology, radiotherapy, epidemiology, and psychology. This guideline was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The clinical questions were collected and selected based on preliminary open-ended questionnaires and subsequent discussions during the Guideline Working Group meetings. PubMed, Web of Science, Cochrane Library, Scopus, and China National Knowledge Infrastructure (CNKI) were searched for available evidence. The GRADE system was used to evaluate the quality of evidence and grade the strengths of recommendations. Finally, the recommendations were developed through a structured consensus-building process.

RESULTS

The Guideline Development Group initially collected a total of 62 important clinical questions. After a series of consensus-building conferences, 24 clinical questions were identified and corresponding recommendation were ultimately developed, focusing on neoadjuvant therapy, perioperative management, adjuvant therapy, postoperative psychological rehabilitation, prognosis assement, and follow-up protocols for NSCLC.

CONCLUSIONS

This guideline puts forward reasonable recommendations focusing on neoadjuvant therapy, perioperative management, adjuvant therapy, postoperative psychological rehabilitation, prognosis assessment, and follow-up protocol of NSCLC. It standardizes perioperative multimodality treatment and provides guidance for clinical practice among thoracic surgeons, medical oncologists, and radiotherapists, aiming to reduce postoperative recurrence, improve patient survival, accelerate recovery, and minimize postoperative complications such as atelectasis.

Clinical features of immune checkpoint inhibitor-related pneumonitis in older patients with lung cancer receiving immune checkpoint inhibitors-based therapy: a retrospective study

BACKGROUND

Older patients with lung cancer are underrepresented in pivotal trials of immune checkpoint inhibitors (ICIs). This study primarily retrospectively evaluated the older patients with lung cancer treated with ICIs to determine which factors are related to the occurrence and prognosis of ICI-related pneumonitis (CIP).

METHODS

We conducted a single-center, retrospective study of patients age ≥ 65 years diagnosed with lung cancer who received ICIs between January 2018 and June 2023 at the First Hospital of China Medical University. Clinical characteristics and blood parameters at baseline (before ICIs), at onset of pneumonitis (in the CIP group), and before the last dose of ICIs (in the non-CIP group) were collected and compared.

RESULTS

A total of 205 older patients with lung cancer were included, of which 51 (24%) patients developed CIP. Radiotherapy history, first line treatment, and the increased baseline systemic immune-inflammation index (SII), and CD4/CD8 were significantly and independently associated with the risk of CIP. Significant increase in CRP and decrease in albumin (ALB), prognostic nutritional index (PNI), and PaO2 were observed from baseline to CIP during treatment with ICIs. The PD-L1 expression status < 50% (P = 0.022) was the risk factor affecting their progression free survival (PFS). ECOG PS ≥ 2 (P = 0.031) and high-CRP (P = 0.007) of older patients were significantly correlated with their overall survival (OS), and patients who experienced CIP had a better OS than non-CIP (P = 0.001). The older patients with interstitial lung abnormalities (ILA) showed a shorter PFS than those without ILA (P = 0.036), and the PD-L1 expression status < 50% (P = 0.005), and low ALB (P = 0.023) was correlated with the OS in CIP.

CONCLUSIONS

Radiotherapy history, first line treatment (mostly in combination therapy), and increased baseline SII and CD4/CD8 were associated with the occurrence of CIP in older patients with lung cancer. PD-L1 expression status < 50%, ECOG PS ≥ 2 and high-CRP were associated with worse prognosis in all older patients. ILA, PD-L1 expression status < 50% and low-ALB at onset of CIP were related to poor prognosis in CIP.

Case Report: A rare case of sintilimab-induced dermatomyositis in a patient with gastric cancer

The PD-1 inhibitor sintilimab has been approved for the treatment of various malignancies. Here, we reported a rare case of sintilimab-induced dermatomyositis in a patient with gastric cancer and liver metastasis to raise awareness of this serious adverse event. A 64-year-old man presented with the onset of gastric cancer and liver metastasis and received two cycles of sintilimab plus nab-paclitaxel. The patient experienced fever, thrombocytopenia, and rash during the first-cycle treatment, followed by bilateral ptosis, dysphagia, slurred speech, and myalgia during the second-cycle treatment. Elevated muscle enzymes, electromyography, and positive myositis antibodies confirmed the diagnosis of dermatomyositis. He was treated with high-dose corticosteroids and immunoglobulin, resulting in symptom improvement. This case widens the spectrum of immune-related toxicity associated with sintilimab, as well as highlights the need for early recognition and management of these events in patients receiving ICIs.

Immune checkpoint inhibitor-related myocarditis in patients with lung cancer

BACKGROUND

The clinical characteristics of immune checkpoint inhibitors (ICIs)-related myocarditis in lung cancer remains uncertain. The purpose of this study was to evaluate the incidence, clinical characteristics, risk factors, and prognosis of myocarditis in lung cancer patients treated with ICIs. Therefore, this study would enhance the understanding of immune related myocarditis in lung cancer population.

METHODS

A total of 1004 patients were analyzed, among those who developed elevated serum creatine kinase isoenzyme, MB form (CK-MB) and/or high-sensitivity troponin I (hs-cTnI) with electrocardiographic or clinical symptoms after immunotherapy were enrolled in the myocarditis group. The same number of patients who had received immunotherapy but didn't develop myocarditis was randomly selected as the control group. Clinicopathologic features, risk factors, and prognostic factors were evaluated in this study.

RESULTS

66 patients (6.6%) developed ICIs-related myocarditis. In these patients, there were 60 case of possible myocarditis (90.9%), 5 probable myocarditis (7.6%), and 1 definite myocarditis (1.5%). The median time to the occurrence of myocarditis was 3.8 months. The median progression-free survival (PFS) for NSCLC and SCLC patients were 24.4 months and 13.0 months, while the median overall survival (OS) for NSCLC and SCLC patients were 43.3 months and 44.6 months. The grade of myocarditis (OR: 5.79; 95%CI: 1.14-29.41, P = 0.034), immunotherapy cycle (OR: 0.38; 95% CI: 0.16-0.92, P = 0.032), and combination of immune-related adverse events (irAEs) (OR: 3.63; 95% CI: 1.55-8.48, P = 0.003) were the influencing factors of PFS in NSCLC patients. In SCLC patients, the immunotherapy cycle was the influential factor for PFS (OR: 0.16; 95%CI: 0.04-0.61, P = 0.007) and OS (OS: 0.12; 95% CI: 0.03-0.48, P = 0.002). Anti-PD1 therapy (OR: 0.4, 95% CI: 0.13-0.97, P = 0.043) and age (OR: 0.36, 95% CI: 0.16-0.84, P = 0.018) might be the protective factors of myocarditis patients compared with the control group.

CONCLUSIONS

The presentations of ICIs-related myocarditis in lung cancer are mainly possible myocarditis and probable myocarditis, which have a mild impact on the prognosis. More cycles of ICI treatment accompany the longer the PFS and OS, as a protective factor. Anti-PD1 therapy and older age may be protective factors for ICI-related myocarditis.

Hepatic immune-related adverse event increased the overall survival of patients with malignancies treated with immune checkpoint inhibitors

BACKGROUND AND AIM

Associations between the occurrence of abnormal liver function tests, an immune-related adverse event (irAE) caused by immune checkpoint inhibitors (ICIs), and treatment efficacy are unclear. We investigated the association between the incidence of these hepatic irAE occurrences and treatment response in patients treated with ICIs.

METHODS

We studied 924 patients treated with ICIs to determine the relationship between the incidence of irAEs and overall survival (OS) with and without the continuation of ICIs due to hepatic irAEs.

RESULTS

Of 924 treated, 338 (36.6%) developed all types of irAEs. Median OS for patients with and without irAEs were 34.3 months (n = 338) and 13.1 months (n = 586), respectively (p = 2.49 × 10-14). Of 924, 62 (6.7%) patients developed hepatic irAE; 31 discontinued and 31 continued ICI. Of interest, median OS with and without the continuation of ICI therapy due to hepatic irAEs was 54.3 months and 11.5 months, respectively (p = 0.00589). We further compared the difference of liver function tests among the two groups. Although aminotransferases are higher among discontinued group, stigmata of impending hepatic failure were no different among these two groups.

CONCLUSIONS

In patients who developed hepatic irAEs, OS was longer in the continued treatment group than in the discontinued treatment group. Most patients who developed hepatic irAEs and stopped the treatment had higher aminotransferase, but often lacks the stigmata of impending hepatic failure such as prothrombin time prolongation or gradual elevation of total bilirubin. Multi-disciplinary cooperation, including hepatologists, may be important for OS improvement by the prolonged use of ICIs.

Mapping immunotherapy potential: spatial transcriptomics in the unraveling of tumor-immune microenvironments in head and neck squamous cell carcinoma

Head and neck squamous cell carcinoma (HNSCC) often exhibits poor response rates to immune checkpoint inhibitor (ICI) therapies, largely owing to the intricate composition and spatial organization of immune cells within the tumor-immune microenvironment (TIME). The diversity of immune cell populations, their spatial relationships, and dynamic interactions significantly influence the immunosuppressive nature of the TIME, thereby limiting the efficacy of immunotherapy. To address these challenges and enhance the therapeutic potential of ICIs in HNSCC, a comprehensive analysis of the TIME is essential. Spatial transcriptomics (ST), a cutting-edge technology, enables high-resolution mapping of gene expression within the spatial context of the tumor, providing critical insights into the functional roles and interactions of immune cells in the TIME. This review highlights the importance of ST in uncovering the complexities of the TIME in HNSCC and proposes strategies for leveraging these insights to develop more effective immunotherapeutic approaches. By integrating spatial and molecular information, this review aims to pave the way for personalized and precision-based treatments in HNSCC, ultimately improving patient outcomes.

Identification of the PROMs used to assess ICI toxicities and HRQoL in patients receiving immune checkpoint inhibitor treatment in cancer care and their suitability: A systematic review

BACKGROUND

The implementation of patient-reported outcome measures (PROMs) in the clinical identification of immunotherapy toxicities is a complex intervention. There has been very little work evaluating the clinical utility and generalisability of PROMs used after immune checkpoint inhibitor (ICI) treatment to date. We reviewed evidence on the use of PROMs assessing toxicities and health-related quality of life in patients treated with ICIs.

METHODS

PubMed, EMBASE, MEDLINE, PsycInfo, CINAHL, Web of Knowledge, the Cochrane Library were searched (January 2008 - October 2024). Quantitative studies reporting the use of PROMs to identify, assess and manage toxicities at any timepoint and HRQoL associated with ICI treatment in adult patients with cancer were included. A narrative synthesis describes the key characteristics of the PROMs identified.

RESULTS

43 studies were included; 12 on melanoma/skin, 12 on lung and 19 on other cancers. Study designs included 20 randomised controlled trials, 14 cohort studies, six cross-sectional studies and three non-randomised interventional trials. The lack of ICI-specific PROMs was highlighted, particularly as the PROMs used lacked sufficient sensitivity for ICI treatments.

CONCLUSIONS

There is need for an ICI-specific PROM for effective assessment of toxicities and a tailored PROM for assessment of HRQoL. Some suggested key domains by certain studies for ICI-specific PROMs include: (a) ICI-specific items (e.g. certain USD-I and PRO-CTCAE items) to capture symptoms associated with ICI treatments such as rash, myalgia, (b) role, psychological, emotional and social functioning domains within HRQoL assessments and (c) additional patient-reported toxicities not included in existing PROMs. Findings emphasize the importance of using a disease-specific PROM that is applicable, acceptable and sufficiently sensitive to identify toxicities and HRQoL issues across all stages.

Real-World Evaluation of Immune-Related Endocrinopathies in Metastatic NSCLC Patients Treated with ICIs in Romania

(1) Background: Exploring real-world data (RWD) regarding immune-related adverse events (irAEs) is crucial to better understand the efficacy and safety of immunotherapy in cancer patient populations excluded from clinical trials. An analysis was conducted to evaluate the presumptive predictive causality between endocrine irAEs and the efficacy of immune check-point inhibitors (ICIs) in metastatic non-small-cell lung cancer (mNSCLC) patients treated in daily practice in Romania. (2) Methods: This was a retrospective cohort study of mNSCLC patients treated with ICIs in a tertiary level hospital in Romania for a period of almost seven years, from November 2017 till July 2024. Endocrine irAEs were well defined as any occurring autoimmune endocrinopathy during ICIs and related to immunotherapy. The hospital endocrinologist (M.C.C.O) diagnosed, treated, and followed these endocrine irAEs in a multidisciplinary approach. We investigated multiple medical variables to assess their impact on ICI effectiveness. Descriptive and statistical analyses were performed. (3) Results: Of 487 cancer patients treated with ICIs, we identified 215 mNSCLC patients who were evaluated for endocrine irAEs and co-medications during ICI therapy. Forty-seven (21.8%) patients experienced endocrine irAEs, thyroiditis being the most frequent and prevalent autoimmune endocrinopathy in 60% of cases. Endocrine irAEs were statistically significant, correlated with ICI efficacy (p = 0.002) for survival analysis. Steroids and proton-pump inhibitors used as co-medication during ICIs had a negative impact on response to therapy. (4) Conclusions: Endocrine irAEs might be considered predictive biomarkers for successful immunotherapy in mNSCLC patients. Co-medication during ICIs had a major influence on the effectiveness of these cutting-edge therapies. RWD plays an important role for oncology daily practice whenever clinical trial evidence is not available to guide decision.

Prognostic Role of SETDB2 in Clear Cell Renal Cell Carcinoma: Linking Immune Infiltration, Cuproptosis, and Tumor Suppression

Background

Clear cell renal cell carcinoma (ccRCC) is a relatively frequently diagnosed form of urological cancer that is highly malignant and associated with high rates of patient mortality. At present, there are few effective options for treating advanced cases of ccRCC, emphasizing the need to establish novel biomarkers and targets suitable for therapeutic intervention. SET domain bifurcated histone lysine methyltransferase 2 (SETDB2) belongs to the Su(var)3-9 subfamily of methyltransferases and has been linked to various forms of cancer, but the role it plays in ccRCC remains to be fully established.

Methods

Data on SETDB2 expression were downloaded from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases. Functional enrichment analyses were then used to probe the putative role that SETDB2 plays in the onset of ccRCC. The Gene Set Cancer Analysis (GSCA) platform and molecular docking analysis were utilized to investigate the relationship between gene expression and drug sensitivity. In the end, the core target and the active molecule were both given the green light for a molecular docking investigation. Functional assays and Western blotting performed with ccRCC cell lines were employed for the validation of the findings from these predictive analyses.

Results

SETDB2 downregulation was observed in ccRCC, and lower levels were found to linked with poor patient outcomes. Lower SETDB2 levels were associated with worse overall, progression-free, and disease-specific survival. In Functional enrichment analyses, SETDB2 was predicted to regulate key ccRCC development-associated pathways. SETDB2 levels were also significantly associated with cuproptosis induction in KIRC tissues, while in immune cell infiltration analyses, SETDB2 expression was linked with immune responses within the tumor microenvironment. Functional experiments conducted with ccRCC cell lines unveiled molecular mechanisms through which SETDB2 appears to be capable of inhibiting the development of ccRCC.

Conclusion

Together, these analyses highlight the utility of SETDB2 as a prognostic biomarker in ccRCC. The interactions and associated pathways detected through these analyses provide unique insight into the potential functions of SETDB2 in this cancer type, providing an evidence base for future studies.

The Role of Eosinophils, Eosinophil-Related Cytokines and AI in Predicting Immunotherapy Efficacy in NSCLC Cancer

Immunotherapy and chemoimmunotherapy are standard treatments for non-oncogene-addicted advanced non-small cell lung cancer (NSCLC). Currently, a limited number of biomarkers, including programmed death-ligand 1 (PD-L1) expression, microsatellite instability (MSI), and tumor mutational burden (TMB), are used in clinical practice to predict benefits from immune checkpoint inhibitors (ICIs). It is therefore necessary to search for novel biomarkers that could be helpful to identify patients who respond to immunotherapy. In this context, research efforts are focusing on different cells and mechanisms involved in anti-tumor immune response. Herein, we provide un updated literature review on the role of eosinophils in cancer development and immune response, and the functions of some cytokines, including IL-31 and IL-33, in eosinophil activation. We discuss available data demonstrating a correlation between eosinophils and clinical outcomes of ICIs in lung cancer. In this context, we underscore the role of absolute eosinophil count (AEC) and tumor-associated tissue eosinophilia (TATE) as promising biomarkers able to predict the efficacy and toxicities from immunotherapy. The role of eosinophils and cytokines in NSCLC, treated with ICIs, is not yet fully understood, and further research may be crucial to determine their role as biomarkers of response. Artificial intelligence, through the analysis of big data, could be exploited in the future to elucidate the role of eosinophils and cytokines in lung cancer.

Cemiplimab and diabetic ketoacidosis: a case report of a rare endocrinopathy associated with immune checkpoint inhibitors

Background

Immune checkpoint inhibitors (ICIs) have revolutionised the cancer treatment landscape in the last decades, improving the outcome of several tumours, such as cutaneous squamous cell carcinoma (cSCC). ICIs are antibodies blocking several immune checkpoint pathways, as cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death 1 (PD-1) with its ligand PD-L1. However, the activation of immune response can cause a broad range of side effects, called immune-related adverse events (irAEs). Endocrine irAEs are mainly represented by thyroid dysfunctions (thyrotoxicosis or hypothyroidism) and hypophysitis, while adrenal insufficiency and diabetes mellitus (DM) are less common. Diabetic ketoacidosis (DKA) is a potential life-threatening presentation of ICI-induced insulin-dependent DM (IDDM). This report presents a rare case of DKA and IDDM secondary to anti-PD-1 antibody cemiplimab therapy, and this is the third described in the literature to date.

Case presentation

We describe the case of a 62-year-old female patient with metastatic perianal squamous cell carcinoma who developed DKA and IDDM after the fifth cycle of cemiplimab. Hyperglycemia (1187 mg/dL), metabolic acidosis (pH 7.27) with bicarbonate levels of 11.9 mmol/L, arterial partial pressure of carbon dioxide of 25.7 mmHg with increased anion gap (equal to 25), and hyperketonuria were present. Adequate glycaemic control was difficult to maintain, and intravenously therapy (insulin, sodium bicarbonate, potassium, and fluids) was required for a long time. Subcutaneous basal-bolus insulin treatment was started, but glycaemic control was scarce, also due to the concomitant administration of prednisone for immune-related hepatotoxicity, until the subject's death.

Conclusion

This report underlines the importance of the awareness on endocrine irAEs with ICIs, particularly life-threatening DKA. A baseline assessment of glycemia and glycated hemoglobin is mandatory, and we recommend a close monitoring of glycemic trend over time during ICIs therapy. Patients and their caregivers should be informed and counselled to recognise DKA signs and symptoms.

Early-Onset Autoimmune Hemolytic Anemia from Pembrolizumab in a Patient with Metastatic Lung Cancer: A Case Report

BACKGROUND Immunotherapy is now a well-established systemic anticancer treatment in both curative and palliative settings in oncology. Immune-related adverse events associated with pembrolizumab, a novel humanized therapeutic monoclonal antibody, very rarely affect the hematologic system. While previous reports have noted autoimmune hemolytic anemia occurring after multiple cycles of immunotherapy, this article describes a case of a patient with advanced lung adenocarcinoma, who was diagnosed with autoimmune hemolytic anemia shortly after his first cycle. CASE REPORT In this article, we report a rare case of autoimmune hemolytic anemia, occurring after 1 cycle of pembrolizumab, in a 69-year-old man with metastatic lung adenocarcinoma. He presented with new-onset severe anemia, jaundice, and dyspnea 14 days after his first cycle of pembrolizumab. The remarkable findings in the initial investigations included hyperbilirubinemia, severe anemia, markedly elevated serum lactate dehydrogenase levels, and positive direct and indirect antiglobulin (Coombs) test results. He had an urgent specialist review at presentation, and was promptly started on high-dose steroids, intravenous immunoglobins, blood transfusions, and other supportive treatments, with subsequent resolution of hemolysis over the next few days. He made a good clinical and hematological recovery and was discharged home after 5 days of hospitalization. CONCLUSIONS Autoimmune hemolytic anemia is a rare adverse effect of immunotherapy, which can be life-threatening without prompt recognition and appropriate management. This case also shows that this disease should be considered as a differential diagnosis of new-onset anemia or sudden-onset jaundice in patients on immunotherapy, regardless of the number of cycles received.

Real-world comparison of the efficacy of first-line therapies and the influence of risk factors in advanced renal cell carcinoma

INTRODUCTION

Systemic therapy for advanced renal cell carcinoma (aRCC) has become increasingly diverse. In the 1st-line setting, various combination therapies are available, with little comparative data on the efficacy of the therapies. The aim of this study was to compare the current 1st-line combination therapies under real-life conditions and to investigate risk factors in the patient population.

METHODS

Patients with aRCC who started 1st-line IO/IO or IO/TKI combination  therapy between 03/2019 and 10/2023 were included. The primary endpoints were progression-free survival (PFS) and overall survival (OS). Secondary endpoints were time on treatment (ToT), duration of response (DoR), subsequent therapies, the evaluation of risk factors and their influence on PFS and OS. Survival data were analysed using Kaplan-Meier estimates with log-rank tests, risk factors for PFS and OS using Cox regression analysis.

RESULTS

A total of 59 patients, mainly men (79.7%) with a median age of 64.8 years were included. The median follow-up was 21 months. The comparison of IO/IO vs. IO/TKI demonstrated a median PFS of 6 (2.08-9.92) vs. 14 (9.06-18.94) months (47 events; HR IO/TKI vs. IO/IO: 0.53 (0.29-0.99); p = 0.039) and a median OS of 20 (15.07-24.94) vs. 33 (21.68-44.32) months (32 deaths; HR IO/TKI vs. IO/IO: 0.74 (0.36-1.51); p = 0.403). Off all risk factors analysed only synchronous metastases proved to be of independent predictive value for PFS (HR 2.38; 95% CI 1.11-5.11; p = 0.026) and OS (HR 3.47; 95% CI 1.15-10.44; p = 0.027).

CONCLUSION

An IO/TKI therapy showed a significantly improved PFS in the real-world setting compared to an IO/IO combination. In terms of OS, the improved treatment response of the IO/TKI group did not prevail.

Dermatitis bullosa caused by the immune checkpoint inhibitor camrelizumab: A case report

BACKGROUND

Since the advent of the 20th century, alongside the progression of medical science and technological advancements, immunotherapy has emerged as a pivotal therapeutic approach for tumor patients subsequent to undergoing radiotherapy and chemotherapy. Arimab (camrelizumab), a flagship drug in the realm of immunotherapy, functions as a monoclonal antibody specifically targeting the programmed death protein 1 (PD-1). This drug engages with the human PD-1 receptor, effectively inhibiting the PD-1/programmed death ligand 1 signaling pathway. This inhibition results in the restoration of T cell activity and the induction of an anti-tumour response. However, it is noteworthy that such interference could lead to immune-related adverse events resembling autoimmune reactions. The growing availability and clinical use of immune checkpoint inhibitors have raised significant clinical concerns regarding their safety. Numerous instances of immune-related adverse reactions and the associated management strategies have been extensively reported. Timely identification and diagnosis, coupled with multidisciplinary consultation and the prompt administration of immunosuppressants, can effectively address severe immune-related adverse reactions.

CASE SUMMARY

Arimab (camrelizumab), a monoclonal antibody targeting programmed death protein 1 (PD-1), disrupts the PD-1/ programmed death ligand 1 (PD-L1) interaction, reactivating T cell function and triggering anti-tumor immunity. However, this disruption may trigger immune-mediated adverse events akin to autoimmune disorders. Approximately 2.8% of such events manifest as immune-related dermatologic reactions, with 0.7% classified as grade 3, which are infrequently documented. Here, this study describes a case of grade 3 bullous dermatitis occurring 15 days after initiating camrelizumab therapy. The patient, a 67-year-old male with oesophageal squamous cell carcinoma, received camrelizumab plus paclitaxel alongside chemotherapy and radiotherapy in early 2022. Due to disease progression, maintenance monotherapy with camrelizumab (200 mg) commenced in June 2022. On the fourth cycle, 15 days into treatment, the patient presented with an immune-checkpoint inhibitor-related rash, despite unremarkable test results. Dermatology and pharmacy consultations were conducted, leading to glucocorticoid therapy, topical interventions, and supportive care. Gastric mucosal protection, nutritional supplementation, and other adjunctive treatments were also provided. The patient's symptoms resolved within 15 days post-discharge, resulting in discontinuation of camrelizumab. Like other PD-1 inhibitors, camrelizumab is associated with immune-mediated dermatitis. Thus, optimal management of these events requires a multidisciplinary approach, vigilant monitoring, regular evaluations, prompt glucocorticoid administration, and specialized dermatologic care.

CONCLUSION

The increasing adoption of immune checkpoint inhibitors in clinical practice has prompted substantial concerns about their safety profile. A wide range of immune-related adverse events and corresponding management strategies have been well-documented. Early recognition and accurate diagnosis, combined with interdisciplinary collaboration and swift initiation of immunosuppressive therapy, are essential in managing severe immune-related adverse reactions effectively. This report details the treatment trajectory and outcome of a case involving immune-related cutaneous adverse reactions, providing pertinent clinical insights for future cases.

Antibody-Free Immunopeptide Nano-Conjugates for Brain-Targeted Drug Delivery in Glioblastoma Multiforme

Glioblastoma Multiforme (GBM) represents a significant clinical challenge amongst central nervous system (CNS) tumors, with a dismal mean survival rate of less than 8 months, a statistic that has remained largely unchanged for decades (National Brain Society, 2022). The specialized intricate anatomical features of the brain, notably the blood-brain barrier (BBB), pose significant challenges to effective therapeutic interventions, limiting the potential reach of modern advancements in immunotherapy to impact these types of tumors. This study introduces an innovative, actively targeted immunotherapeutic nanoconjugate (P12/AP-2/NCs) designed to serve as an immunotherapeutic agent capable of traversing the BBB via LRP-1 receptor-mediated transcytosis. P12/AP-2/NCs exert its immune-modulating effects by inhibiting the PD-1/PD-L1 axis through a small-size PD-L1/PD-L2 antagonist peptide Aurigene NP-12 (P12). P12/AP-2/NCs are synthesized from completely biodegradable, functionalized high molecular weight β-poly(L-malic acid) (PMLA) polymer, conjugated with P12 and Angiopep-2 (AP2) to yield P12/AP-2/NCs. Evaluating nanoconjugates for BBB permeability and 3-D tumor model efficacy using an in vitro BBB-Transwell spheroid based model demonstrating successful crossing of the BBB and internalization in brain 3D tumor environments. In addition, the nanoconjugate mediated T cell's cytotoxicity on 3D tumor region death in a U87 GBM 3-D spheroid model. AP2/P12/NCs is selectively inhibited in PD1/PDL1 interaction on T cells and tumor site, increasing inflammatory cytokine secretion and T cell proliferation. In an in-vivo murine brain environment, rhodamine fluorophore-labeled AP2/P12/NCs displayed significantly increased accumulation in the brain during 2-6 h time intervals post-injection with a prolonged bioavailability over unconjugated peptides. AP2/P12/NCs demonstrated a safety profile at both low and high doses based on major organ histopathology evaluations. Our findings introduce a novel, programmable nanoconjugate platform capable of penetrating the BBB for directed delivery of small peptides and significant immune environment modulation without utilizing antibodies, offering promise for treating challenging brain diseases like glioblastoma multiforme and beyond.

Management of Immunotherapy-Induced Type 1 Diabetes

One of the life-threatening adverse effects associated with the use of immune checkpoint inhibitors is β cells destruction resulting in type 1 diabetes. Immune checkpoint inhibitor-induced type 1 diabetes (ICI-T1D) usually has a rapid onset requiring admission to the intensive care unit for the management of diabetic ketoacidosis using an insulin drip protocol. Once stabilized patients with ICI-T1D are started on insulin therapy to mimic usual pancreatic function. Insulin administration may be through multiple daily injections or continuous subcutaneous insulin infusions using an insulin pump. People who develop ICI-T1D will require insulin therapy for life.

Concomitant antihistamine administration is associated with improved survival outcomes in patients with locally advanced or metastatic urothelial carcinoma treated with atezolizumab. Analysis of individual participant data from IMvigor210 and IMvigor211

OBJECTIVES

Survival outcomes of patients with metastatic urothelial carcinoma (mUC) are still suboptimal and strategies to enhance response to immune-oncology (IO) compounds are under scrutiny. In preclinical studies, it has been demonstrated that antihistamines may reverse macrophage immunosuppression, reactivate T cell cytotoxicity, and enhance the immunotherapy response. We aimed to evaluate the role of concomitant antihistamines administration on oncological outcomes among patients with mUC.

MATERIALS AND METHODS

We relied on individual patient data from IMvigor210 (phase II single-arm trial on second line atezolizumab for mUC) and IMvigor211 trials (phase III randomized trial on second line atezolizumab vs chemotherapy for mUC). Among individuals treated with IO we identified patients who did and did not receive antihistamines. Multivariable Cox or competing-risks regression models were used to predict progression-free survival (PFS), overall survival (OS), and cancer-specific survival (CSS). The impact of antihistamines on the outcomes was assessed after adjusting for potential confounders.

RESULTS

Among 896 patients with locally advanced or metastatic urothelial cancer who had progressed after first-line chemotherapy, 155 (17 %) received antihistamines during the delivery of IO. Patients receiving antihistamines had longer OS (Hazard Ratio [HR]:0.59; 95 % Confidence interval [CI]: 0.47-0.74; P < 0.001), PFS (HR:0.70; 95 %CI: 0.57-0.87; P = 0.001) and CSS [sHR:0.58; 95 %CI:0.45-0.75; P < 0.001)] relative to those who had not used antihistamine drugs. A sensitivity analysis, after the exclusion of patients who experienced adverse events and received antihistamines, yielded similar findings of prolonged CSS (sHR 0.78; 95 %CI: 0.59-0.98, P = 0.031) and OS (HR 0.71; 95 %CI: 0.52-0.94, P = 0.021).

CONCLUSIONS

Concomitant antihistamines administration was associated with improved OS, CSS, and PFS in patients receiving atezolizumab as second line treatment for mUC. Further mechanistic and clinical investigation is warranted to elucidate the role of antihistamines in IO.

Immune Checkpoint Inhibitor-associated Pneumonitis: A Narrative Review

Immune checkpoint inhibitors (ICI), such as pembrolizumab, nivolumab, durvalumab and ipilimumab, have significantly enhanced survival rates for multiple cancer types such as non-small cell lung cancer, melanoma, Hodgkin lymphoma, and breast cancer, and they have emerged as an adjunct or primary therapy for malignant disease. Approximately 40% of patients with cancer on ICI therapy experience side effects called immune-related adverse events (irAE). While not the most common, pulmonary toxicities can be rapidly progressive, potentially fatal, and pose a three-fold increased risk for requiring intensive care unit-level of care. Pneumonitis is a focal or diffuse inflammation of the lung parenchyma, and clinical manifestations may be highly variable. While the onset is generally observed 6-12 weeks after the initiation of therapy, drug toxicity can develop rapidly within days after the first infusion or many months into therapy. Pneumonitis symptoms can be subtle or non-specific; therefore, a thorough and systematic evaluation considering other possible etiologies is crucial. Moreover, extrapulmonary findings, such as skin lesions, colitis, or endocrinopathies, should raise suspicion for irAE as drug toxicity can affect multiple organs simultaneously. Due to the significant overlap of clinical features between ICI-associated pneumonitis and respiratory infections, it can be challenging to differentiate the two conditions based on clinical presentation alone. A multidisciplinary approach to management is recommended for the treatment of ICI-associated pneumonitis, and classification of severity helps to guide interventions. Treatment options in more severe cases include systemic immunosuppression. Given the increased use of ICIs and greater probability that patients with ICI-associated pneumonitis will be seen in the emergency department, we aimed to provide a comprehensive framework for the diagnosis and management. In addition, identifying potential challenges in diagnosis and/or other contributors of respiratory symptoms and radiographic manifestations is highlighted.

Pathophysiology, diagnosis, and management of immune checkpoint inhibitor-induced diabetes mellitus

Immune Checkpoint Inhibitors (ICIs) have revolutionized cancer treatment, offering hope for patients with various malignancies. However, along with their remarkable anticancer effects, ICIs can also trigger immune-related adverse events (irAEs). One such noteworthy complication is the development of Diabetes Mellitus (DM), which particularly resembles Type 1 Diabetes Mellitus (T1DM). The aim of this review is to provide insights into the epidemiology, pathophysiology, diagnostic issues, and treatment considerations of ICI-induced DM (ICI-DM), emphasizing the importance of early recognition and management to mitigate adverse outcomes. Although still rare, the incidence has increased with the widespread use of ICIs, especially PD-1/PD-L1 blockers (from 0.2% to 1.9%). Factors affecting the development of ICI-DM, such as specific ICIs, patient demographics, and genetic predispositions, are discussed. The complex interplay between immune dysregulation and pancreatic β-cell destruction contributes to diagnostic challenges, with presentations varying from asymptomatic hyperglycemia to diabetic ketoacidosis (DKA). Management strategies prioritize meticulous glycemic and electrolyte regulation along with tailored intravenous insulin therapy in cases of DKA. DM remission is rare, therefore treatment with both long-acting insulin at bedtime and short-acting insulin before meals is needed in longterm. Total daily insulin requirements can be estimated at 0.3-0.4 units/kg/day for most patients as a starting dose.

Gastrointestinal toxicities associated with immune checkpoint inhibitors therapy: risks and management

Immune checkpoint inhibitors (ICIs) have greatly improved cancer treatment by boosting the immune system's ability to target tumors. However, they can also cause serious side effects, particularly in the digestive system. These include immune-related diarrhea, inflammation of the intestines and, less commonly, inflammation of the stomach or esophagus. This review underscores the importance of early detection, accurate diagnosis, and timely treatment to improve patient outcomes. It also highlights the need for further research to develop strategies to reduce gastrointestinal toxicities and enhance the overall effectiveness of ICIs in cancer therapy.

Current Landscape and Future Directions in Cancer Immunotherapy: Therapies, Trials, and Challenges

Cancer remains a leading global health challenge, placing immense burdens on individuals and healthcare systems. Despite advancements in traditional treatments, significant limitations persist, including treatment resistance, severe side effects, and disease recurrence. Immunotherapy has emerged as a promising alternative, leveraging the immune system to target and eliminate tumour cells. However, challenges such as immunotherapy resistance, patient response variability, and the need for improved biomarkers limit its widespread success. This review provides a comprehensive analysis of the current landscape of cancer immunotherapy, highlighting both FDA-approved therapies and novel approaches in clinical development. It explores immune checkpoint inhibitors, cell and gene therapies, monoclonal antibodies, and nanotechnology-driven strategies, offering insights into their mechanisms, efficacy, and limitations. By integrating emerging research and clinical advancements, this review underscores the need for continued innovation to optimise cancer immunotherapy and overcome existing treatment barriers.

Therapeutic advances in multiple sclerosis: Novel therapies (immune checkpoint inhibitors, CAR-T, Anti-CD40L)

As patients with multiple sclerosis (MS) age, the risk of cancer also increases. Immune checkpoint inhibitors (ICIs) are novel monoclonal antibodies that have revolutionized cancer treatment. However, their use is limited by immune related adverse events. In patients with MS and pre-existing autoimmune disease there is concern that use of ICIs could worsen disease outcome. In the first part of this review we discuss the current data on ICIs and MS which overall suggest that they are well tolerated from the standpoint of MS disease activity. We recommend that MS not be a strict contraindication to ICI use which should depend on an individualized risk benefit discussion. In the second part, we focus on novel therapies for MS including CAR-T cell and anti-CD40L treatments. These newer therapies have the potential to address an unmet need in MS as they can cross the blood-brain and have the potential to target compartmentalized central nervous inflammation that may underly the pathophysiology of progressive MS.

Troponin i-induced cardiac inflammation and dysfunction in mice: a comparative study with the AT-3 tumor-bearing model

BACKGROUND

Myocarditis is a potentially fatal condition, with a mortality rate of up to 50% in severe cases. Studies, including those by Nobel Laureate Honjo, have implicated autoantibodies against cardiac troponin I (cTnI) in driving cardiac inflammation in mice. Research has also identified autoantibodies under baseline conditions in some cancer models. However, data on the effects of recombinant cTnI on autoantibody production, myocardial inflammation, and contractile function remain limited. This study investigated cTnI-associated myocardial inflammation and autoantibody formation in both tumor-free and tumor-bearing mouse models.

METHODS

Female BALB/c mice were immunized with recombinant cTnI combined with adjuvants and compared to adjuvant-only controls. Cardiac function was assessed using gated cardiac MRI, including myocardial velocities, acceleration, deceleration, and standard volumetric parameters including ejection fraction (EF). Anti-cTnI autoantibodies were quantified using a custom-designed ELISA, while myocardial inflammation was assessed by analyzing T-cell subsets (CD4 + and CD8 +) in myocardial tissue samples. Baseline autoantibody reactivity was evaluated in tumor-bearing mice and tumor-free controls for comparison.

RESULTS

The left ventricular ejection fraction trended lower in the cTnI + adjuvant group (57.80 ± 1.7%) compared to controls (61.67 ± 4.1%), but the difference was not statistically significant (p = 0.073). Myocardial velocity, reflecting contraction speed, was significantly reduced in cTnI-treated mice (control:-1.2 ± 0.8 cm/s; cTnI:-1.05 ± 0.07 cm/s; p = 0.015). Anti-cTnI autoantibody levels increased significantly in cTnI-treated mice at 8 weeks (control:0.1 ± 0.02; cTnI:0.77 ± 0.28; p = 0.007). Additionally, the density of CD8 + T-cells in myocardial tissue was significantly higher in the cTnI group (control:2.2 ± 1.2 cells/mm2; cTnI:4.4 ± 2 cells/mm2; p = 0.013), indicating an enhanced cytotoxic T-cell response. The CD4/CD8 ratio was significantly lower in cTnI-treated mice (control: 8.2 ± 6.8; cTnI:3.1 ± 0.9; p = 0.029), further suggesting a shift toward a cytotoxic immune profile. Baseline autoantibody reactivity in tumor-bearing mice was not significantly different from controls (tumor-bearing: absorbance 0.049 ± 0.029; control: absorbance 0.068 ± 0.05 at 450 nm), indicating no inherent autoimmune reactivity in the tumor-bearing model.

CONCLUSIONS

Recombinant cTnI induces myocardial contractile dysfunction and promotes a cytotoxic immune response, supporting its role as an autoantigen in myocarditis. Advanced cardiac MRI revealed subtle functional impairments that EF alone could not detect. These findings highlight the potential for therapies targeting cTnI-induced autoimmunity, particularly in patients with ICI-associated myocarditis.

Efficacy of high-dose steroids versus low-dose steroids in the treatment of immune checkpoint inhibitor-associated myocarditis: a case series and systematic review

BACKGROUND

Immune checkpoint inhibitor-associated myocarditis (ICI-M) is a rare yet potentially fatal complication of immunotherapy, with no standardized treatment protocol due to limited data. The use of varying steroid doses has resulted in inconsistent outcomes.

METHODS

We retrospectively identified patients diagnosed with ICI-M at our institution between January 2020 and February 2024. Additionally, we conducted a comprehensive literature review using PubMed, Embase, and the Cochrane Library to facilitate a comparative analysis of clinical responses. The primary aim was to compare clinical outcomes and therapeutic responses between patients treated with high-dose versus low-dose methylprednisolone.

RESULTS

Patients receiving an initial high-dose intravenous methylprednisolone (1 g/day) exhibited a more rapid reduction in myocardial injury markers, including troponin I/T (cTnI/T), creatine kinase (CK), and N-terminal pro b-type natriuretic peptide (NT-proBNP), compared to those receiving lower doses. This group also demonstrated lower incidences of biomarker rebound and maintained lower levels over time. Additionally, the clinical treatment process was more straightforward in the high-dose group, with treatment efficacy surpassing that observed in patients who received an initial methylprednisolone (mPSL) dose of less than 1 g/day. Regarding prognosis, the incidence of major adverse cardiovascular events (MACE) and cardiovascular mortality was significantly lower in the high-dose group compared to the low-dose group.

CONCLUSIONS

In patients with immune checkpoint inhibitor-associated myocarditis, the prompt administration of high-dose corticosteroid pulse therapy (1 g/day) is strongly associated with improved clinical outcomes. This intervention rapidly lowers myocardial injury biomarkers (cTnI/T, CK, NT-proBNP) while minimizing the risk of biomarker rebound, thus optimizing clinical management. Notably, it significantly reduces the incidence of major adverse cardiovascular events (MACE), thereby enhancing patient prognosis. The duration of therapy should be tailored based on clinical response. In cases of steroid resistance, combination therapies may provide additional benefit.

Traditional Chinese medicine enhances the effectiveness of immune checkpoint inhibitors in tumor treatment: A mechanism discussion

ETHNOPHARMACOLOGICAL RELEVANCE

Immune checkpoint inhibitors (ICIs) have altered the landscape of tumor immunotherapy, offering novel therapeutic approaches alongside surgery, chemotherapy, and radiotherapy and significantly improving survival benefits. However, their clinical efficacy is limited in some patients, and their use may cause immune-related adverse events (irAEs). Integrating traditional Chinese medicine (TCM) with ICIs has demonstrated the potential to boost sensitization and reduce toxicity. Clinical trials and experimental explorations have confirmed that TCM and its active components synergistically enhance the effectiveness of ICIs.

AIMS

This narrative review summarizes the TCM practices that enhance the clinical efficacy and reduce irAEs of ICIs. This paper also summarizes the mechanism of experimental studies on the synergies of Chinese herbal decoctions, Chinese herbal preparation, and Chinese herbal active ingredients. Most of the studies on TCM combined with ICIs are basic experiments. We discussed the mechanism of TCM enhanced ICIs to provide reference for the research and development of TCM adjuvant immunotherapy.

METHODS

We conducted a literature search using PubMed and Chinese National Knowledge Infrastructure databases, with a focus on herbal decoction, Chinese medicine preparations, and active ingredients that boost the effectiveness of ICIs and reduce irAEs. The search keywords were "ICIs and traditional Chinese medicine", "PD-1 and traditional Chinese medicine", "PD-L1 and traditional Chinese medicine", "CTLA-4 and traditional Chinese medicine", "IDO1 and traditional Chinese medicine", "Tim-3 and traditional Chinese medicine", "TIGIT and traditional Chinese medicine", "irAEs and traditional Chinese medicine". The search period was from May 2014 to May 2024. Articles involving the use of TCM or its components in combination with ICIs and investigating the underlying mechanisms were screened. Finally, 30 Chinese medicines used in combination with ICIs were obtained to explore the mechanism. In the part of immune checkpoint molecules other than PD-1, there were few studies on the combined application of TCM, so studies involving the regulation of immune checkpoint molecules by TCM were included.

RESULTS

TCM has been shown to boost the effectiveness of ICIs and reduce irAEs. Researchers indicate that TCM and its active components can work synergistically with ICIs by regulating immune checkpoints PD-1, PD-L1, CTLA-4, and IDO1, regulating intestinal flora, improving tumor microenvironment and more.

CONCLUSIONS

Combining TCM with ICIs can play a better anti-tumor role, but larger samples and high-quality clinical trials are necessary to confirm this. Many Chinese medicines and their ingredients have been shown to sensitize ICIs in experimental studies, which provides a rich choice for the subsequent development of ICI enhancers.

Late-Onset Myocarditis Following Immune Checkpoint Inhibitors Therapy: A Case Series with Literature Review

Immune checkpoint inhibitors (ICIs) therapy has revolutionized cancer treatment. However, it is important to acknowledge that ICI therapy can lead to immune-related adverse events (irAEs), including myocarditis. While early-onset myocarditis is well-documented, late-onset cases are increasingly recognized. This case series presents four cases of late-onset ICI-associated myocarditis, emphasizing the need for long-term surveillance of this potentially fatal complication. Patients exhibited a range of cardiac symptoms, including chest pain, shortness of breath, and arrhythmias. The diagnosis was confirmed through cardiac magnetic resonance imaging (MRI) and elevated cardiac biomarkers. Treatment involved the immediate discontinuation of ICI therapy and the initiation of high-dose corticosteroids. In cases with an inadequate response, additional immunosuppressive agents were considered. This case series underscores the importance of prolonged monitoring for late-onset ICI-associated myocarditis. Further research is needed to establish optimal treatment strategies and long-term management approaches for this complex condition.

Immune checkpoint inhibitors in cancer patients from the perspective of pharmaceutical care: a scoping review

BACKGROUND

Cancer treatment has become a significant health challenge, with notable changes in recent years due to increasing knowledge of cancer biology. The use of immune checkpoint inhibitors (ICIs) has shown promising results, but they can induce adverse events (AEs), resulting in serious consequences for patients. Pharmaceutical care aims to prevent, identify, and address issues related to medications, such as AEs.

AIM

The objective of this scoping review was to assess the contribution of pharmacists to the intervention and care of cancer patients undergoing treatment with ICIs.

METHODS

The PubMed, Scopus, Embase, and Web of Science databases were searched for studies on the treatment of cancer patients treated with ICIs in which pharmacists participated. No time frame or language restriction was applied. Article screening was performed independently by two authors, with any discrepancies resolved by a third author. The studies were analyzed and included in this review following the inclusion and exclusion criteria.

RESULTS

Nine studies fulfilled the inclusion criteria. Pharmaceutical care encompasses a variety of interventions, including providing guidance to patients and to the multidisciplinary team, monitoring and managing AEs, conducting pharmaceutical consultations, and recommending over-the-counter medications and laboratory tests, among other actions. Pharmaceutical recommendations led to better outcomes regarding AEs.

CONCLUSIONS

Pharmaceutical care has a positive impact on oncological immunotherapy with ICIs, contributing to both health institutions through cost reduction and, most importantly, patients by improving treatment outcomes and enhancing the quality of life.

Cancer therapy-related interstitial lung disease

ABSTRACT

With the increasing utilization of cancer therapy, the incidence of lung injury associated with these treatments continues to rise. The recognition of pulmonary toxicity related to cancer therapy has become increasingly critical, for which interstitial lung disease (ILD) is a common cause of mortality. Cancer therapy-related ILD (CT-ILD) can result from a variety of treatments including chemotherapy, targeted therapy, immune checkpoint inhibitors, antibody-drug conjugates, and radiotherapy. CT-ILD may progress rapidly and even be life-threatening; therefore, prompt diagnosis and timely treatment are crucial for effective management. This review aims to provide valuable information on the risk factors associated with CT-ILD; elucidate its underlying mechanisms; discuss its clinical features, imaging, and histological manifestations; and emphasize the clinical-related views of its diagnosis. In addition, this review provides an overview of grading, typing, and staging treatment strategies used for the management of CT-ILD.

Drug-Induced Liver Injury Associated With Emerging Cancer Therapies

Targeted therapies and immunotherapies have shown great promise as best-in-class treatments for several cancers with respect to efficacy and safety. While liver test abnormalities are rather common in patients treated with kinase inhibitors or immunotherapy, events of severe hepatotoxicity in these patients are rare in comparison with those associated with chemotherapeutics. The underlying mechanisms and risk factors for severe hepatotoxicity with novel oncology therapies are not well understood, complicating the drug-induced liver injury (DILI) risk assessment in the preclinical and clinical phases of drug development. The epidemiological and clinical characteristics, as well as mechanisms of liver toxicity, are described here to the current state of knowledge. Tools to study and assess the risk of DILI during drug development are concisely summarised, focusing on caveats thereof for novel oncology treatments. Emerging tools to optimise safety assessments and gather additional mechanistic insights into DILI are introduced. Particularly in oncology, where standard liver signals during drug development are tolerated to a marginally higher degree than in other indications due to the life-saving, life-extending and quality-of-life improvements for patients with severe or advanced cancers versus previous standard-of-care therapeutics, safety assessments must be tailored to the drug and indication. Trends in patient safety-centred drug development programmes and regulatory approval processes must continually be revisited and streamlined via obtaining an overall greater understanding of DILI and the tools available to assess mechanisms of injury, frequency, severity and prognosis.

[Acute kidney injury in cancer patients receiving immune checkpoint inhibitor therapy-shared guidelines of FITC/SFNDT]

Cancer treatments have been dramatically modified by the introduction and the development of immunological checkpoint inhibitors (ICI). These treatments have many side effects, including acute kidney injury (AKI). Their combination with other treatments makes the diagnosis complex. To provide guidance to physicians treating these patients, the FITC and the SFNDT have developed a set of management guidelines covering pre-treatment assessment, diagnosis of the different types of damage observed, and management of acute interstitial nephritis secondary to ICI. Collaboration between oncologists and nephrologists is mandatory. The development of onconephrology is helping to improve knowledge and identify treatment pathways. The key elements of the diagnostic process are presented. The role of renal biopsy is discussed, as it appears to be underused in relation to the expected benefits. Renal biopsy allows ICI to be continued if AKI is not related to AKI. Treatment based on glucocorticoid therapy is recommended, with regimens depending on the severity of the disease and the renal response to glucocorticoid therapy. Alternative treatments for patients resistant to corticosteroids are discussed, but strong data are lacking. Rechallenge should be discussed since it seems to be associated with a good renal prognosis.