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Tarafdar N, Sachdeva M, Savinova I, Sood S, Bagit A, Waked JAA, Abduelmula A, Lytvyn Y, Maliyar K, Georgakopoulos JR, Mufti A, Yeung J. Cutaneous Granulomatous Reactions in Patients Treated with Immune Checkpoint Inhibitors: A Systematic Review. J Cutan Med Surg 2024:12034754241274273. [PMID: 39225265 DOI: 10.1177/12034754241274273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Affiliation(s)
- Nawar Tarafdar
- Western University, Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Muskaan Sachdeva
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Iryna Savinova
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Siddhartha Sood
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, ON, Canada
| | - Ahmed Bagit
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, ON, Canada
| | - Jihad Abou Ali Waked
- Western University, Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Abrahim Abduelmula
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Yuliya Lytvyn
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Khalad Maliyar
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Asfandyar Mufti
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Jensen Yeung
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Probity Medical Research, Waterloo, ON, Canada
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Jo NC, Shroff GS, Ahuja J, Agrawal R, Price MC, Wu CC. Radiation Recall Pneumonitis: Imaging Appearance and Differential Considerations. Korean J Radiol 2024; 25:843-850. [PMID: 39197829 PMCID: PMC11361796 DOI: 10.3348/kjr.2024.0334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/22/2024] [Accepted: 07/24/2024] [Indexed: 09/01/2024] Open
Abstract
Radiation recall pneumonitis is an inflammatory reaction of previously radiated lung parenchyma triggered by systemic pharmacological agents (such as chemotherapy and immunotherapy) or vaccination. Patients present with non-specific symptoms such as cough, shortness of breath, or hypoxia soon after the initiation of medication or vaccination. Careful assessment of the patient's history, including the thoracic radiation treatment plan and timing of the initiation of the triggering agent, in conjunction with CT findings, contribute to the diagnosis. Once a diagnosis is established, treatment includes cessation of the causative medication and/or initiation of steroid therapy. Differentiating this relatively rare entity from other common post-therapeutic complications in oncology patients, such as recurrent malignancy, infection, or medication-induced pneumonitis, is essential for guiding downstream clinical management.
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Affiliation(s)
- Nahyun Celina Jo
- Department of Diagnostic Radiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Girish S Shroff
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jitesh Ahuja
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rishi Agrawal
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Melissa C Price
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, MA, USA
| | - Carol C Wu
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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3
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Morin C, Villeneuve T, Norkowski E, Rosencher L, Cadranel J, Mazières J. Sarcoid-like reaction related to ALK-ROS inhibitors in lung cancer patients. Respir Med Res 2024; 86:101138. [PMID: 39288551 DOI: 10.1016/j.resmer.2024.101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 08/03/2024] [Accepted: 08/17/2024] [Indexed: 09/19/2024]
Affiliation(s)
- Clara Morin
- Pulmonology Department, University Hospital of Toulouse, 24 Chemin de Pouvourville, 31059, Toulouse, Cedex, France; Centre de Recherche en Cancérologie de Toulouse (CRCT), Inserm, CNRS, University of Toulouse III Paul Sabatier, 2 Avenue Hubert Curien, 31100, Toulouse, France.
| | - Thomas Villeneuve
- Pulmonology Department, University Hospital of Toulouse, 24 Chemin de Pouvourville, 31059, Toulouse, Cedex, France
| | - Emma Norkowski
- Medipath, Pathology, 116 route d'espagne, 31100, Toulouse, France
| | - Lise Rosencher
- Pulmonology and Thoracic Oncology Department, APHP Hôpital Tenon and Sorbonne University, 4 rue de la Chine, 75020, Paris, France
| | - Jacques Cadranel
- Pulmonology and Thoracic Oncology Department, APHP Hôpital Tenon and Sorbonne University, 4 rue de la Chine, 75020, Paris, France
| | - Julien Mazières
- Pulmonology Department, University Hospital of Toulouse, 24 Chemin de Pouvourville, 31059, Toulouse, Cedex, France; Centre de Recherche en Cancérologie de Toulouse (CRCT), Inserm, CNRS, University of Toulouse III Paul Sabatier, 2 Avenue Hubert Curien, 31100, Toulouse, France
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4
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Rizzo M, Pezzicoli G, Ganini C, Carone L, Caliò A, Brunelli M, Cosmai L, Porta C. Sarcoidosis-like reactions in metastatic renal cell carcinoma patients treated with immune-based combinations. Immunotherapy 2024; 16:603-609. [PMID: 38980662 PMCID: PMC11290368 DOI: 10.1080/1750743x.2024.2342222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/09/2024] [Indexed: 07/10/2024] Open
Abstract
Aim: The incidence of drug-induced sarcoidosis-like reactions (DISR) in patients treated with immune checkpoint inhibitors (ICIs) is rising. We determine the incidence and characteristics of DISR in a metastatic renal cell carcinoma (mRCC) population. Methods: We retrospectively reviewed clinico-radiological data of 83 mRCC patients treated at a single institution with immune-based combinations. Results: 15 patients received immune-doublet (ipilimumab-nivolumab), while 68 patients received other immune-based combinations. Two cases of DISR (2.4%) were evidenced, with enlargement of mediastinal lymph nodes that mimicked disease progression, thus requiring a biopsy which showed histological features of DISR. Conclusion: In our series of the incidence of DISR, radiological and clinical features, are in line with literature. DISR diagnosis is often only radiological, and its occurrence is possibly associated with a better outcome.
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Affiliation(s)
- Mimma Rizzo
- Division of Medical Oncology, A.O.U. Consorziale Policlinico di Bari, Bari, Italy
| | - Gaetano Pezzicoli
- Interdisciplinary Department of Medicine, University of Bari “A. Moro”, Bari, Italy
| | - Carlo Ganini
- Interdisciplinary Department of Medicine, University of Bari “A. Moro”, Bari, Italy
| | - Luisa Carone
- Institute of Radiology, I.R.C.C.S. San Matteo University Hospital Foundation, Pavia, Italy
| | - Anna Caliò
- Department of Diagnostic & Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Matteo Brunelli
- Department of Diagnostic & Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Laura Cosmai
- Onconephrology Outpatient Clinic, Division of Nephrology & Dialysis, A.S.S.T. Fatebenefratelli-Sacco, Milan, Italy
| | - Camillo Porta
- Division of Medical Oncology, A.O.U. Consorziale Policlinico di Bari, Bari, Italy
- Interdisciplinary Department of Medicine, University of Bari “A. Moro”, Bari, Italy
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5
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Ladouceur A, Ezdoglian A, Sparks JA, Hudson M, Jamal S, Clifford A, Roberts J, Ye C. The Utility of Laboratory Investigations for the Assessment and Management of Rheumatic Immune Related Adverse Events. Rheum Dis Clin North Am 2024; 50:181-199. [PMID: 38670720 DOI: 10.1016/j.rdc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have greatly improved survival of several cancers with historically very poor prognosis. ICIs act by stimulating the patient's own immune system to fight cancer. Simultaneously, this immune activation can lead to immune-related adverse events (irAEs), including rheumatic manifestations (Rh-irAEs). Rh-irAEs mimic primary rheumatic diseases including arthritis, polymyalgia rheumatica, myositis, vasculitis, sarcoidosis, and sicca. This article summarizes the latest evidence regarding the utility of laboratory investigations in Rh-irAEs.
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Affiliation(s)
- Alexandra Ladouceur
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - Aiarpi Ezdoglian
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, VU University Medical Center (VUmc), De Boelelaan 1118, Amsterdam 1081 HZ, the Netherlands
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Suite 6016U, Boston, MA 02115, USA
| | - Marie Hudson
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, Lady Davis Institute for Medical Research, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - Shahin Jamal
- Arthritis Research Canada, Department of Medicine, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel Street, Ste 8205B, Vancouver, British Columbia V5Z 1M9, Canada
| | - Alison Clifford
- Faculty of Medicine & Dentistry, Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, Alberta T6G 2G3, Canada
| | - Janet Roberts
- Division of Rheumatology, Department of Medicine, Queen Elizabeth II Health Sciences Center and Dalhousie University, Nova Scotia rehabilitation and Arthritis Centre, Arthritis Research Canada; Lady Davis Institute for Medical Research, 1341 Summer Street, Halifax, Nova Scotia B3H 4K4, Canada
| | - Carrie Ye
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, Alberta T6G 2G3, Canada.
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Tam K, Wallace M, Mulrennan S. Recommencement of atezolizumab with associated pulmonary sarcoid-like reaction. Respirol Case Rep 2024; 12:e01363. [PMID: 38680668 PMCID: PMC11052663 DOI: 10.1002/rcr2.1363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
An 81 year old male with Child-Pugh A cirrhosis and metastatic hepatocellular carcinoma (HCC) treated with 3-weekly atezolizumab and bevacizumab developed a pulmonary sarcoid-like reaction (SLR) after 5 months. Atezolizumab, an immune checkpoint inhibitor, was identified as the likely culprit. He was treated with prednisolone, resulting in improvement, and was successfully rechallenged with both atezolizumab and bevacizumab.
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Affiliation(s)
- Khai Tam
- Respiratory and Hepatology DepartmentSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Michael Wallace
- Respiratory and Hepatology DepartmentSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Siobhain Mulrennan
- Respiratory and Hepatology DepartmentSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
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7
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Chua DYS, Ong CSH, Goh BYS, Tan NJH. Renal mass-forming granulomatous inflammation associated with immune checkpoint inhibitor therapy. Pathology 2024; 56:421-423. [PMID: 37716817 DOI: 10.1016/j.pathol.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 06/30/2023] [Indexed: 09/18/2023]
Affiliation(s)
- Darren Yee Shuen Chua
- Department of Pathology, National University Hospital, National University Health System, Singapore
| | - Chloe Shu Hui Ong
- Department of Urology, National University Hospital, National University Health System, Singapore
| | - Benjamin Yen Seow Goh
- Department of Urology, National University Hospital, National University Health System, Singapore
| | - Nicholas Jin Hong Tan
- Department of Pathology, National University Hospital, National University Health System, Singapore.
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8
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Shrateh ON, Abugharbieh Y, Asbeh YA, Hour H, Awad I, Bannoura S. Sarcoid-like reaction and hypothyroidism induced by PD-1 inhibitor treatment in metastatic renal cell carcinoma: a case report and literature review. BMC Pulm Med 2024; 24:123. [PMID: 38459507 PMCID: PMC10924379 DOI: 10.1186/s12890-024-02943-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/01/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Pembrolizumab is among the approved treatments for a variety of cancer types, including clear cell renal cell carcinoma (ccRCC). It has contributed to enhancing the prognosis of renal cell carcinoma. However, it is essential to be aware of the numerous potential immune-related side effects associated with its use. CASE PRESENTATION A 69-year-old patient with a history of metastatic renal cell carcinoma has been undergoing treatment with Pembrolizumab, an immune checkpoint inhibitor. The medication has led to the development of a sarcoid-like reaction, initially misinterpreted as cancer recurrence and progression. Additionally, the patient has experienced new-onset hypothyroidism, which has been attributed to the immunotherapy. CONCLUSION Clinicians, including oncologists, endocrinologists, and radiologists, should maintain a high level of suspicions and awareness regarding the potential adverse events associated with newly introduced immunotherapies like pembrolizumab. This knowledge is crucial for the accurate diagnosis and appropriate management of patients receiving these treatments.
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Affiliation(s)
- Oadi N Shrateh
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine.
| | | | - Yousef Abu Asbeh
- Department of Thoracic Surgery, Al-Ahli Hospital, Hebron, Palestine
| | - Hani Hour
- Department of Oncology, Al-Ahli Hospital, Hebron, Palestine
| | - Iyad Awad
- Deparment of Radiology, Al-Ahli Hospital, Hebron, Palestine
| | - Sami Bannoura
- Department of Pathology, Al-Ahli Hospital, Hebron, Palestine
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9
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Torrecilla-Vall-Llossera C, Jucglà Serra A, Molinero Caturla J, Moreno-Vílchez C, Penín Mosquera RM, Marcoval Caus J. Sarcoid-like Reactions to Immune Checkpoint Inhibitors. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:80-83. [PMID: 37482293 DOI: 10.1016/j.ad.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 07/25/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) can cause immune-mediated cutaneous adverse events, including sarcoid-like reactions. The aim of this study was to retrospectively analyze clinical and histologic data from patients who developed cutaneous sarcoid-like reactions between 2019 and 2022 while under treatment with ICIs. We studied 7 patients (6 women and 1 man) with a median age of 65years. Median time to onset of symptoms was 4months. The most common presentation was papular sarcoidosis of the knees followed by subcutaneous sarcoidosis. Diagnosis was confirmed histologically in all cases, and no differences were observed relative to idiopathic sarcoidosis. Discontinuation of ICI therapy was required in just two patients. ICI-induced sarcoid-like reactions tend to be mild and generally do not require treatment discontinuation. Histologic confirmation is essential for distinguishing these reactions from tumor progression.
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Affiliation(s)
- C Torrecilla-Vall-Llossera
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España.
| | - A Jucglà Serra
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - J Molinero Caturla
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - C Moreno-Vílchez
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - R M Penín Mosquera
- Servicio de Anatomía Patológica, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - J Marcoval Caus
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
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10
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Torrecilla-Vall-Llossera C, Jucglà Serra A, Molinero Caturla J, Moreno-Vílchez C, Penín Mosquera RM, Marcoval Caus J. [Translated article] Sarcoid-like Reactions to Immune Checkpoint Inhibitors. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T80-T83. [PMID: 37923080 DOI: 10.1016/j.ad.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/01/2023] [Indexed: 11/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) can cause immune-mediated cutaneous adverse events, including sarcoid-like reactions. The aim of this study was to retrospectively analyze clinical and histologic data from patients who developed cutaneous sarcoid-like reactions between 2019 and 2022 while under treatment with ICIs. We studied 7 patients (6 women and 1 man) with a median age of 65years. Median time to onset of symptoms was 4months. The most common presentation was papular sarcoidosis of the knees followed by subcutaneous sarcoidosis. Diagnosis was confirmed histologically in all cases, and no differences were observed relative to idiopathic sarcoidosis. Discontinuation of ICI therapy was required in just two patients. ICI-induced sarcoid-like reactions tend to be mild and generally do not require treatment discontinuation. Histologic confirmation is essential for distinguishing these reactions from tumor progression.
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Affiliation(s)
- C Torrecilla-Vall-Llossera
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | - A Jucglà Serra
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - J Molinero Caturla
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - C Moreno-Vílchez
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - R M Penín Mosquera
- Servicio de Anatomía Patológica, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - J Marcoval Caus
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
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11
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Torres-Zurita A, Vázquez-Montero L, Gallego-López L, Mediano-Rambla MD, de la Cruz-Merino L. Sarcoidosis-like reaction induced by immune checkpoint inhibitor in a patient with hepatocellular carcinoma: a case report. Front Immunol 2023; 14:1150128. [PMID: 37781378 PMCID: PMC10533992 DOI: 10.3389/fimmu.2023.1150128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Nowadays, immune checkpoint inhibitors (ICI) have become the cornerstone of treatment for many tumors, either as monotherapy or in combination with other therapies. However, these drugs are associated with several new side effects that need early detection. We present the case of a 41-year-old male patient who has been diagnosed with advanced hepatocellular carcinoma (HCC) with metastatic retroperitoneal lymph nodes and a subdiaphragmatic metastatic lesion, undergoing second-line treatment with a combination of nivolumab and ipilimumab. After completing four cycles, the patient was admitted to the hospital due to intermittent fever and profuse sweating. A CT scan showed multiple pathologically enlarged lymph nodes in several locations, raising suspicion of disease progression. The patient's clinical progress was favorable after symptomatic treatment (antipyretics) and was discharged one week after admission. Several days later, the patient complained about painful bilateral ocular redness and was diagnosed with bilateral anterior uveitis. Further blood tests showed elevated angiotensin-converting enzyme (ACE) levels of 67 U/L (normal range: 8 - 52) and decreasing alpha-fetoprotein (AFP) levels of 698 ng/mL (previously 1210 ng/mL), indicative of non-progression of the oncological disease. Finally, an excisional biopsy confirmed the presence of non-necrotizing granulomatous lymphadenitis, leading to the diagnosis of sarcoidosis-like reaction (SLR) induced by immunotherapy as the etiology of the polyadenopathy syndrome. SLR, although uncommon, is an adverse effect of ICI treatment resulting from immune system dysregulation, which can mimic disease progression. It is crucial to be aware of this adverse event and to understand the optimal management approach.
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Affiliation(s)
- Alberto Torres-Zurita
- Department of Clinical Oncology, Virgen Macarena University Hospital, Seville, Spain
| | - Lucía Vázquez-Montero
- Department of Clinical Oncology, Virgen Macarena University Hospital, Seville, Spain
| | - Laura Gallego-López
- Department of Internal Medicine, Virgen Macarena University Hospital, Seville, Spain
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Mazumder A, Mehrmal S, Chaudhry S. Immunotherapy-induced exclusively cutaneous sarcoid-like reaction. BMJ Case Rep 2023; 16:e252766. [PMID: 37463781 PMCID: PMC10357716 DOI: 10.1136/bcr-2022-252766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Sarcoid-like reactions (SLRs) are rare, granulomatous inflammatory reactions to immune checkpoint inhibitors (ICIs) that can involve any organ but frequently affect the lungs, mediastinal lymph nodes and skin. We present a rare case of an exclusively cutaneous SLR due to pembrolizumab that clinically resembled dermatomyositis. A literature review yielded only 12 previously reported cases of ICI-induced cutaneous SLR without any systemic involvement. Our case highlights the diversity of presentations of cutaneous SLR and emphasises the importance of histological evaluation of new cutaneous eruptions.
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Affiliation(s)
- Anika Mazumder
- Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Sino Mehrmal
- Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Sofia Chaudhry
- Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
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13
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Sagawa T, Sato Y, Nagashima H, Takada K, Takahashi M, Hirakawa M, Hamaguchi K, Tamura F, Fujikawa K, Okamoto K, Kawano Y, Sogabe M, Miyamoto H, Takayama T. Hilar/mediastinal and cutaneous drug-induced sarcoidosis-like reaction associated with immune checkpoint inhibitors in metastatic colorectal cancer: a case report. Front Immunol 2023; 14:1203621. [PMID: 37492584 PMCID: PMC10365267 DOI: 10.3389/fimmu.2023.1203621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) are the standard treatment for metastatic colorectal cancer (mCRC) with high microsatellite instability (MSI-H). Among immune-related adverse events (irAEs), drug-induced sarcoidosis-like reactions (DISR) are often difficult to differentiate from cancer progression. Main Body This is a case of a woman in her mid-60s, with mCRC (RAS wild/BRAF mutant/MSI-H) and abdominal lymph node metastasis, treated with four courses of ipilimumab + nivolumab every 3 weeks, followed by nivolumab every 2 weeks as third-line treatment. After treatment, the original lymph node metastases shrank, but hilar/mediastinal lymph nodes appeared. Endoscopic ultrasound-guided fine-needle aspiration of these lymph nodes revealed multiple epithelioid granulomas without necrosis, indicating a sarcoidosis-like reaction. Fluorodeoxyglucose-positron emission tomography scan showed abnormal subcutaneous accumulation in bilateral forearms and bilateral knee joints. Biopsy of the cutaneous lesions was also performed, which revealed epithelioid granulomas. As the patient had no symptoms in other organs, no specific therapeutic intervention was administered. After the discontinuation of immunotherapy, the sarcoidosis-like reaction regressed without cancer relapse. Conclusions Clinicians should be aware of the possibility of DISR as an irAE during the ICI treatment of mCRC. In suspected cases of DISR following ICI therapy, it is important to differentiate between cancer progression and DISR through histological diagnosis for the subsequent strategy, as radiological and serological findings are not definitive.
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Affiliation(s)
- Tamotsu Sagawa
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Hokkaido, Japan
| | - Yasushi Sato
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Hiroyuki Nagashima
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Hokkaido, Japan
| | - Kohichi Takada
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Mamoru Takahashi
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Masahiro Hirakawa
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Hokkaido, Japan
| | - Kyoko Hamaguchi
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Hokkaido, Japan
| | - Fumito Tamura
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Hokkaido, Japan
| | - Koshi Fujikawa
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Hokkaido, Japan
| | - Koichi Okamoto
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yutaka Kawano
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Masahiro Sogabe
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Hiroshi Miyamoto
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Tetsuji Takayama
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
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Plachouri KM, Florou V, Georgiou V, Georgiou S. Cutaneous Side Effects of Modern Targeted Therapy and Immunotherapy in Patients with Dermatological Malignancies. Cancers (Basel) 2023; 15:3126. [PMID: 37370736 DOI: 10.3390/cancers15123126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/24/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
The advent of immunotherapy and targeted therapies in treating dermatological malignancies has dramatically changed the landscape of dermato-oncology in recent years. Their superior efficacy compared to previous therapeutic options, such as chemotherapy, has resulted in their use in treating devastating malignancies, such as melanoma or unresectable/metastatic basal cell and squamous cell carcinoma. Skin toxicity is a critical safety consideration, among other adverse reactions, that can occur under treatment with these agents. This article aims to summarize the cutaneous side effects of immune checkpoint inhibitors and targeted dermato-oncological therapies. Although the skin side effects of these agents are primarily mild, they can occasionally affect the decision for treatment continuation and the quality of life of the affected patients. Therefore, physicians must be acquainted with the specific cutaneous toxicity profile of such treatments to mitigate their impact on the patients and optimize the overall outcome of dermato-oncological therapy.
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Affiliation(s)
- Kerasia-Maria Plachouri
- Dermatology Department, University General Hospital of Patras, University of Patras, 265 04 Rio, Greece
| | - Vaia Florou
- Division of Oncology, Department of Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 841112, USA
| | - Vasileios Georgiou
- School of Medicine, University General Hospital of Patras, University of Patras, 265 04 Rio, Greece
| | - Sophia Georgiou
- Dermatology Department, University General Hospital of Patras, University of Patras, 265 04 Rio, Greece
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15
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Choi R, Wang JX, Damsky W, Wang A, Galan A, Leventhal J. Janus kinase-signal transducers and activators of transcription (JAK-STAT) activation in anti-programmed death-1 (PD-1) therapy-Associated granuloma annulare: a case series. Int J Dermatol 2023; 62:e323-e325. [PMID: 35933688 PMCID: PMC9902571 DOI: 10.1111/ijd.16375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/20/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Rachel Choi
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - Jake X. Wang
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - William Damsky
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Alice Wang
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - Anjela Galan
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan Leventhal
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
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16
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Eljilany I, Noor A, Paravathaneni M, Yassine I, Lee SJ, Othus M, Moon J, Kirkwood JM, Sondak VK, Ribas A, Grossmann KF, Tarhini AA. Granulomatous and Sarcoid-like Immune-Related Adverse Events following CTLA4 and PD1 Blockade Adjuvant Therapy of Melanoma: A Combined Analysis of ECOG-ACRIN E1609 and SWOG S1404 Phase III Trials and a Literature Review. Cancers (Basel) 2023; 15:2561. [PMID: 37174027 PMCID: PMC10177189 DOI: 10.3390/cancers15092561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Treatment with immune checkpoint inhibitors (ICIs) has been linked to granulomatous and sarcoid-like lesions (GSLs) affecting different organs. This study sought to evaluate GSL incidence in patients with high-risk melanoma treated with cytotoxic T-lymphocyte antigen 4 (CTLA4) or programmed cell death 1 (PD1) blockade adjuvant therapy in two clinical trials: ECOG-ACRIN E1609 and SWOG S1404. Descriptions and GSL severity ratings were recorded. METHODS Data were collected from ECOG-ACRIN E1609 and SWOG S1404. Descriptive statistics along with GSL severity grades were reported. Additionally, a literature review for such cases was summarized. RESULTS A total of 11 GSL cases were reported among 2878 patients treated with either ICI or with High-Dose Interferon Alfa-2b (HDI) in ECOG-ACRIN E1609 and SWOG S1404 trials. Cases were numerically more commonly reported with ipi10, followed by pembrolizumab, ipi3, and HDI, respectively. Most of the cases were grade III. Further, organs involved included lung, mediastinal lymph nodes, skin and subcutaneous tissue, and eye. Furthermore, a summary of 62 reports in the literature was described. CONCLUSIONS GSLs following anti-CTLA4 and anti-PD1 antibody therapy in patients with melanoma were reported unusually. Reported cases ranged in grade from I to III and appeared manageable. Careful attention to these events and their reporting will be essential to better guide practice and management guidelines.
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Affiliation(s)
- Islam Eljilany
- Houston Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Arish Noor
- Houston Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | | | - Ibrahim Yassine
- Houston Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
- Department of Psychology, College of Life Sciences, University of California, Los Angeles, CA 90095, USA
| | - Sandra J. Lee
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Megan Othus
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - James Moon
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - John M. Kirkwood
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Vernon K. Sondak
- Houston Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Antoni Ribas
- Department of Psychology, College of Life Sciences, University of California, Los Angeles, CA 90095, USA
| | | | - Ahmad A. Tarhini
- Houston Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
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17
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Nikolaou V, Tsimpidakis A, Stratigos A. Cutaneous Adverse Reactions of Immunotherapy in Patients with Advanced Melanoma. Cancers (Basel) 2023; 15:cancers15072084. [PMID: 37046745 PMCID: PMC10093334 DOI: 10.3390/cancers15072084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Immune checkpoint blockers (ICBs) have been widely used during the last decade for the treatment of various tumors, including advanced and metastatic melanoma. While these agents have improved melanoma patients’ survival rates, they have also been associated with various autoimmune toxicities, with the skin being most commonly affected. The severity of cutaneous toxicity can not only negatively affect patients’ quality of life but can also limit the proper treatment of cancer. Thus, the role of the dermatologist is substantial in early detecting and promptly treating these adverse events. Maculopapular rash, psoriasiform, lichenoid dermatoses and bullous pemphigoid are the most frequent cutaneous adverse events that require immediate intervention. Other rare autoimmune toxicities, e.g., sarcoidosis, dermatomyositis or subacute lupus, have also been reported. In this review, we summarize the aspects of ICB-induced cutaneous toxicities in patients with melanoma, emphasizing their management and treatment options in clinical practice.
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18
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Haanen J, Obeid M, Spain L, Carbonnel F, Wang Y, Robert C, Lyon AR, Wick W, Kostine M, Peters S, Jordan K, Larkin J. Management of toxicities from immunotherapy: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2022; 33:1217-1238. [PMID: 36270461 DOI: 10.1016/j.annonc.2022.10.001] [Citation(s) in RCA: 290] [Impact Index Per Article: 145.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/30/2022] [Accepted: 10/02/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- J Haanen
- Division of Medical Oncology, Netherlands Cancer Institute (NKI), Amsterdam, The Netherlands
| | - M Obeid
- Immunology and Allergy Service, CHUV, Lausanne; Lausanne Center for Immuno-oncology Toxicities (LCIT), CHUV, Lausanne; Department of Oncology, CHUV, Lausanne, Switzerland
| | - L Spain
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne; Department of Medical Oncology, Eastern Health, Melbourne; Monash University Eastern Health Clinical School, Box Hill, Australia
| | - F Carbonnel
- Gastroenterology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Bicêtre, Le Kremlin Bicêtre, France; Université Paris Saclay 11, Le Kremlin-Bicêtre, France
| | - Y Wang
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - C Robert
- Department of Medicine, Gustave Roussy Cancer Centre, Villejuif; Paris-Saclay University, Villejuif, France
| | - A R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, London; National Heart and Lung Institute, Imperial College London, London, UK
| | - W Wick
- Neurology Clinic and National Centre for Tumour Diseases, University Hospital Heidelberg, Heidelberg; DKTK and Clinical Cooperation Unit NeuroOncology, DKFZ, Heidelberg, Germany
| | - M Kostine
- Department of Rheumatology, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - S Peters
- Department of Oncology, CHUV, Lausanne, Switzerland
| | - K Jordan
- Department of Haematology, Oncology and Palliative Medicine, Ernst von Bergmann Hospital Potsdam, Potsdam; Department of Haematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - J Larkin
- Royal Marsden NHS Foundation Trust, London, UK
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Durvalumab-Associated Granulomatous Reaction Mimicking Recurrence of Lung Cancer. Am J Ther 2022; 29:e757-e759. [PMID: 32467499 DOI: 10.1097/mjt.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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20
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Immune checkpoint inhibitors and kidney disease. Curr Opin Nephrol Hypertens 2022; 31:449-455. [PMID: 35894279 DOI: 10.1097/mnh.0000000000000805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICIs) have changed the landscape of cancer treatment. However, use of ICIs can be limited by inflammatory toxicities referred to as immune-related adverse events (irAEs). ICI-associated acute kidney injury (ICI-associated AKI) affects 3-5% of ICI users. RECENT FINDINGS With the rapidly growing indication of ICI, knowledge of ICI-associated kidney toxicity has also expanded from case series to large multicentre cohort studies. In this review, we discuss the clinical features, risk factors, clinicopathological correlations and prognosis of ICI-associated AKI from the most recent rigorously conducted retrospective cohort studies. We also discuss recent advances in diagnostic biomarker investigation, treatment and the unique challenge faced in the kidney transplant population. SUMMARY With more comprehensive understanding of the clinical features and risk factors, ICI-associated AKI is commonly diagnosed clinically, especially given the inherent challenges performing a kidney biopsy in the cancer population; however, this highlights the urgent need for improved noninvasive diagnostic biomarkers to aid diagnosis and prognosis. Prospective studies are needed to better define the optimal treatment of ICI-associated AKI and to minimize the risk of graft loss in patients with kidney transplant who require ICIs.
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21
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Shaikh A. Immunotherapies and Renal Injury. CURRENT OPINION IN TOXICOLOGY 2022; 31:100362. [PMID: 39086475 PMCID: PMC11290437 DOI: 10.1016/j.cotox.2022.100362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Cancer immunotherapy represents a giant leap forward in the management of malignant diseases. An optimal anti-tumor immune response requires cancer antigen recognition by T-cells followed by an effector immune response. Suppression of T-cell activation prevents cancer cell clearance resulting in tumor proliferation. Recent clinical successes of immune checkpoint inhibitors and chimeric antigen receptor T cell therapies has transformed the landscape of cancer immunotherapy. The goal of immunotherapy is to boost host-protective anti-tumor immunity without concomitantly causing immune-related adverse events. However, immunotherapies can cause multiorgan dysfunction including acute kidney injury. Prompt recognition and management of immunotherapy-associated kidney injury is critical in preserving kidney function and improving patient outcomes.
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Affiliation(s)
- Aisha Shaikh
- Renal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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22
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Sachpekidis C, Hassel JC, Dimitrakopoulou-Strauss A. Adverse effects under immune checkpoint inhibitors on [18F]FDG PET/CT imaging. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2022; 66:245-254. [PMID: 35612369 DOI: 10.23736/s1824-4785.22.03453-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Despite their undisputed contribution to the management of various tumors and the prolongation of patient survival, immune checkpoint inhibitors (ICIs) exert their effect at the cost of toxicity. In the context of the activation of the host immune system triggered by ICIs, collateral, inflammatory side effects, commonly addressed as immune-related adverse events (irAEs) often occur. Early detection of irAEs can be critical for adequate decisions on patient management that may subsequently improve patient outcome. Moreover, the emergence of irAEs has been linked with the antitumor effect elicited by ICIs, thus, their identification may potentially provide prognostic information. Although the diagnosis of irAEs is mainly clinical, some adverse events may be asymptomatic and only diagnosed by imaging modalities. At the same time, radiological signs of irAEs are not necessarily associated with clinical symptoms, however, clinicians should be alerted to their presence. Among imaging modalities [18F]FDG PET/CT has shown satisfying efficiency in response assessment and monitoring of ICIs' treatment, especially in patients suffering from metastatic melanoma and lung cancer. In this context, [18F]FDG PET/CT may also be a valuable method for surveillance of irAEs during immunotherapy. This article aims to review the most common adverse events observed on [18F]FDG PET/CT under immunotherapy and summarize potential results linking PET signs of irAEs with response assessment to ICIs.
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Affiliation(s)
- Christos Sachpekidis
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Heidelberg, Germany -
| | - Jessica C Hassel
- Department of Dermatology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), University Hospital of Heidelberg, Heidelberg, Germany
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23
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Taskaynatan H, Gunenc D, Ön S, Mizrak A, Samancilar O, Karaca B. Immunotherapy-induced granulomatous reaction in patients with melanoma. Melanoma Res 2022; 32:286-290. [PMID: 35752875 DOI: 10.1097/cmr.0000000000000815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Immune checkpoint inhibitors (ICIs) represent a new era in stage IV melanoma treatment. These agents are generally well tolerated but have specific side effects. The granulomatous reaction is one of such ICI-related adverse events. In this report, we present the cases of three patients with stage IV melanoma who all developed mediastinal and hilar lymphadenopathy during ICI treatment. While a complete response was observed in one patient, near complete responses were observed in the other two patients. Amid these favorable outcomes, all patients developed mediastinal and hilar lymphadenopathy approximately 6 months after the initiation of immunotherapy. Biopsies were performed to explore the underlying pathology of the lymph nodes, which revealed granulomatous reactions rather than metastases. Hence, immunotherapy was continued in all patients. The development of granulomatous lymphadenitis associated with ICIs may mimic disease recurrence/progression clinically and radiographically. Awareness of such type of adverse event is crucial to decide whether to continue therapy or not.
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Affiliation(s)
| | - Damla Gunenc
- Department of Medical Oncology, Tulay Aktas Oncology Hospital
| | - Sercan Ön
- Department of Medical Oncology, Tulay Aktas Oncology Hospital
| | - Ali Mizrak
- Department of Medical Pathology, School of Medicine, Ege University
| | - Ozgur Samancilar
- Clinic of Thoracic Surgery, Medicana International Hospital, Izmir, Turkey
| | - Burcak Karaca
- Department of Medical Oncology, Tulay Aktas Oncology Hospital
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24
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O'Connor C, Finnegan P, Power DG, Bennett M, Bourke JF. Pembrolizumab-associated erythema nodosum in the treatment of metastatic melanoma. Immunotherapy 2022; 14:1021-1026. [PMID: 35892257 DOI: 10.2217/imt-2021-0239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 66-year-old woman receiving pembrolizumab for metastatic melanoma presented with tender red nodules on her shins and forearms. Biopsy was consistent with erythema nodosum (EN). The eruption responded to oral minocycline and potent topical steroids. Subsequent investigations detected bihilar lymphadenopathy, biopsied as granulomatous lymphadenitis, confirming the diagnosis of pembrolizumab-associated sarcoidosis. Pembrolizumab was stopped for two cycles and was restarted without recrudescence of EN or bihilar lymphadenopathy. Immunotherapy-associated sarcoidosis is a rare but recognized adverse event related to therapy with immune checkpoint inhibitors. EN is an uncommon manifestation of immunotherapy-induced sarcoidosis. New-onset bihilar lymphadenopathy in the context of immunotherapy requires prompt histological evaluation to differentiate between immunotherapy-associated sarcoidosis and metastatic progression. We review the literature related to immunotherapy-associated EN.
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Affiliation(s)
- Cathal O'Connor
- Department of Dermatology, South Infirmary Victoria University Hospital, Cork, T12 X23H, Ireland.,Department of Medicine, University College Cork, Cork, T12 AK54, Ireland
| | - Paula Finnegan
- Department of Dermatology, South Infirmary Victoria University Hospital, Cork, T12 X23H, Ireland
| | - Derek G Power
- Department of Oncology, Cork University Hospital, Cork, T12 DC4A, Ireland.,Department of Medicine, University College Cork, Cork, T12 AK54, Ireland
| | - Mary Bennett
- Department of Dermatology, South Infirmary Victoria University Hospital, Cork, T12 X23H, Ireland.,Department of Medicine, University College Cork, Cork, T12 AK54, Ireland
| | - John F Bourke
- Department of Dermatology, South Infirmary Victoria University Hospital, Cork, T12 X23H, Ireland.,Department of Medicine, University College Cork, Cork, T12 AK54, Ireland
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25
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Purcell V, Preti B, Fernandes R. Suspected immune checkpoint inhibitor-induced pulmonary sarcoid reaction in metastatic renal cell carcinoma. Clin Case Rep 2022; 10:e5960. [PMID: 35846932 PMCID: PMC9272222 DOI: 10.1002/ccr3.5960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/19/2022] [Accepted: 05/30/2022] [Indexed: 01/09/2023] Open
Abstract
We present the case of a 50-year-old male patient with metastatic clear cell renal cell carcinoma (mRCC) who developed a diffuse pulmonary opacification and lymphadenopathy during nivolumab maintenance therapy. This was diagnosed as presumed sarcoid granulomatous inflammatory reaction secondary to immunotherapy, which resolved with holding off therapy and the nivolumab was resumed.
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Affiliation(s)
- Victoria Purcell
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| | - Beatrice Preti
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada,Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada
| | - Ricardo Fernandes
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada,Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada,Cancer Research Laboratory ProgramLawson Health Research InstituteLondonOntarioCanada
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26
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Muacevic A, Adler JR, Coelho R, Carvalheiro C, Rolim I, Garrido P, GIl N, Duarte-Ramos F, Stumpf Tonin FS. The Meaning of Lymphadenopathies During Adjuvant Durvalumab After Chemoradiotherapy for Lung Cancer: Thinking Beyond Disease Progression. Cureus 2022; 14:e26729. [PMID: 35967142 PMCID: PMC9364060 DOI: 10.7759/cureus.26729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/14/2022] Open
Abstract
Immune-checkpoint inhibitors (ICIs) have become the mainstay of treatment for many malignancies. With this new strategy, relevant immune-related adverse events (irAEs) have been reported, some of which can be mistaken for disease progression. To better illustrate the current challenges in diagnosing and managing a patient under adjuvant ICI treatment, we present the case of a 67-year-old female patient with stage IIIB unresectable, epidermal growth factor receptor (EGFR)-mutated, non-small-cell lung cancer who was initially treated with chemoradiotherapy, followed by immunotherapy with durvalumab. During the course of immunotherapy, the patient presented with madarosis and erythematous and endured skin lesions, in addition to lymphadenopathies and pulmonary infiltrates. She was started on first-line palliative treatment with an EGFR tyrosine kinase inhibitor. After reviewing the case, a multidisciplinary team meeting suggested diagnostic procedures, including a transbronchial needle aspiration from mediastinal lymph nodes. The histologic examination showed chronic systemic inflammation and non-caseating granulomas of the sarcoid type. In this case, palliative treatment was suspended and systemic therapy with prednisolone was initiated. The patient became asymptomatic and the previously observed radiologic abnormalities resolved. This case highlights the importance of early recognition and appropriate treatment of irAEs, mainly because these conditions remain poorly understood and are probably underdiagnosed. Considering differential diagnosis is paramount to guide clinical management, despite curative or palliative treatment intent.
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27
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Melin A, Routier É, Roy S, Pradere P, Le Pavec J, Pierre T, Chanson N, Scoazec JY, Lambotte O, Robert C. Sarcoid-like Granulomatosis Associated with Immune Checkpoint Inhibitors in Melanoma. Cancers (Basel) 2022; 14:cancers14122937. [PMID: 35740604 PMCID: PMC9221061 DOI: 10.3390/cancers14122937] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 02/05/2023] Open
Abstract
We aimed to review the clinical and biological presentation of granulomatosis associated with immune-checkpoint inhibitors (ICI) in patients with melanoma and to explore its association with classical sarcoidosis as well as with cancer response to ICI. To this end, a retrospective study on 18 melanoma patients with histologically proven ICI-induced granulomatosis over a 12-year period in a single center, as well as on 67 similar cases reported in the literature, was conducted. Results indicate ICI-induced granulomatosis is an early side effect (median time to onset: 2 months). Its clinical presentation, with predominant (90%) thoracic involvement, histopathological appearance and supposed underlying biology (involving the mTOR pathway in immune cells, Th17 polarization and TReg dysfunction) are indistinguishable from those of sarcoidosis. Moreover, it appears to be associated with ICI benefit (>65% objective response rate). Evolution is generally favorable, and symptomatic steroid treatment and/or ICI discontinuation are rarely necessary. ICI-associated granulomatosis is critical to explore for several reasons. Practically, it is essential to differentiate it from cancer progression. Secondly, this “experimental” sarcoidosis brings new elements that may help to address sarcoidosis origin and pathophysiology. Its association with ICI efficacy must be confirmed on a larger scale but could have significant impacts on patient management and biomarker definition.
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Affiliation(s)
- Audrey Melin
- Department of Dermatology, Gustave Roussy, 114 rue Edouard-Vaillant, 94800 Villejuif, France; (É.R.); (S.R.)
- Correspondence: (A.M.); (C.R.)
| | - Émilie Routier
- Department of Dermatology, Gustave Roussy, 114 rue Edouard-Vaillant, 94800 Villejuif, France; (É.R.); (S.R.)
| | - Séverine Roy
- Department of Dermatology, Gustave Roussy, 114 rue Edouard-Vaillant, 94800 Villejuif, France; (É.R.); (S.R.)
| | - Pauline Pradere
- Service de Pneumologie et Transplantation Pulmonaire, Hôpital Marie-Lannelongue, Groupe Hospitalier Paris-Saint Joseph, 133 Av. de la Résistance, 92350 Le Plessis-Robinson, France; (P.P.); (J.L.P.)
| | - Jerome Le Pavec
- Service de Pneumologie et Transplantation Pulmonaire, Hôpital Marie-Lannelongue, Groupe Hospitalier Paris-Saint Joseph, 133 Av. de la Résistance, 92350 Le Plessis-Robinson, France; (P.P.); (J.L.P.)
| | - Thibaut Pierre
- Department of Medical Imaging, Gustave Roussy, 114 rue Edouard-Vaillant, 94800 Villejuif, France;
| | - Noémie Chanson
- Department of Internal Medicine, Kremlin Bicêtre Hospital, 78 rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France; (N.C.); (O.L.)
| | - Jean-Yves Scoazec
- Université Paris Saclay, AP-HP, 63 rue Gabriel Péri, 94270 Le Kremlin Bicêtre, France;
- Department of Pathology, Gustave Roussy, 114 rue Edouard-Vaillant, 94800 Villejuif, France
| | - Olivier Lambotte
- Department of Internal Medicine, Kremlin Bicêtre Hospital, 78 rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France; (N.C.); (O.L.)
- Université Paris Saclay, AP-HP, 63 rue Gabriel Péri, 94270 Le Kremlin Bicêtre, France;
| | - Caroline Robert
- Department of Dermatology, Gustave Roussy, 114 rue Edouard-Vaillant, 94800 Villejuif, France; (É.R.); (S.R.)
- Université Paris Saclay, AP-HP, 63 rue Gabriel Péri, 94270 Le Kremlin Bicêtre, France;
- Correspondence: (A.M.); (C.R.)
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28
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Immunotherapy pitfall: sarcoid-like reaction mimicking disease progression in advanced melanoma treated with nivolumab. MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2022. [DOI: 10.1007/s12254-022-00806-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Sollena P, Cappilli S, Federico F, Schinzari G, Tortora G, Peris K. "Skin rashes" and immunotherapy in melanoma: distinct dermatologic adverse events and implications for therapeutic management. Hum Vaccin Immunother 2022; 18:1889449. [PMID: 33759689 PMCID: PMC9122307 DOI: 10.1080/21645515.2021.1889449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/24/2021] [Accepted: 02/07/2021] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors have shown efficacy in the treatment of different cancers by stimulating the antitumoral activity of the patient's immune system, representing a major breakthrough in the field of cancer therapy. Monoclonal antibodies including anti-cytotoxic T-lymphocyte-associated protein 4, anti-programmed cell death protein 1 and its ligand inhibitors have been approved for advanced melanoma among other solid cancers. Although immunotherapy demonstrated a good safety profile, a new spectrum of multisystemic immune-related adverse events has been recently reported due to their use. Cutaneous reactions represent one of the leading adverse events, often reported in literature as "skin rash", and rarely further characterized in distinct dermatologic entities. Herein we describe the distinctive cutaneous rashes occurring during immunotherapies for advanced melanoma, discussing implications in the treatment management.
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Affiliation(s)
- Pietro Sollena
- Dermatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simone Cappilli
- Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Federico
- Department of Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Schinzari
- Department of Medical Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giampaolo Tortora
- Department of Medical Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ketty Peris
- Dermatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
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Chen CH, Yu HS, Yu S. Cutaneous Adverse Events Associated with Immune Checkpoint Inhibitors: A Review Article. Curr Oncol 2022; 29:2871-2886. [PMID: 35448208 PMCID: PMC9032875 DOI: 10.3390/curroncol29040234] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as novel options that are effective in treating various cancers. They are monoclonal antibodies that target cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death 1 (PD-1), and programmed cell death-ligand 1 (PD-L1). However, activation of the immune systems through ICIs may concomitantly trigger a constellation of immunologic symptoms and signs, termed immune-related adverse events (irAEs), with the skin being the most commonly involved organ. The dermatologic toxicities are observed in nearly half of the patients treated with ICIs, mainly in the form of maculopapular rash and pruritus. In the majority of cases, these cutaneous irAEs are self-limiting and manageable, and continuation of the ICIs is possible. This review provides an overview of variable ICI-mediated dermatologic reactions and describes the clinical and histopathologic presentation. Early and accurate diagnosis, recognition of severe toxicities, and appropriate management are key goals to achieve the most favorable outcomes and quality of life in cancer patients.
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Affiliation(s)
- Chieh-Hsun Chen
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan;
| | - Hsin-Su Yu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807378, Taiwan;
| | - Sebastian Yu
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan;
- Department of Dermatology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- Correspondence: ; Tel.: +886-7-3121101 (ext. 6103)
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Lin Y, Zhu W, Wu B, Lan H. Case Report: Hepatic Sarcoid-Like Reaction Associated With Checkpoint Inhibition in a NSCLC Patient and a Literature Review. Front Oncol 2022; 12:824308. [PMID: 35359368 PMCID: PMC8960956 DOI: 10.3389/fonc.2022.824308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/15/2022] [Indexed: 12/24/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) treatment has dramatically revolutionized the landscape of therapeutic approaches in multiple cancers, particularly, non-small-cell lung cancer (NSCLC). With the increasing use of programmed death-1 (PD-1) inhibitors in the clinic, the emerging toxicity profile presents a novel learning curve for clinicians. Here we report the first case of an NSCLC patient displaying sarcoid/granulomatous-like reaction (SLR, also known as GLR) in the liver during an anti-PD-1 therapy which showed efficacious response of complete regression. Also, this is the first report describing the SLR induced by toripalimab, a novel PD-1 inhibitor. Given this kind of hepatic findings can be easily mistaken as metastasis, even resulting in premature use of second-line treatments. In particular, we briefly review the clinical features of all those cases reporting sarcoidosis and SLRs manifested on different organs during anti-PD-(L)1 therapy. We anticipate that these clinical cases would help to alert the attention of clinicians that SLRs, as a rare immune-related adverse event (irAE), is manageable and that histopathological analysis is necessary before interpreting it as disease progression.
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Affiliation(s)
- Yuxin Lin
- Department of Oncology, Hospital of Chinese Medicine of Changxing County, Huzhou, China
| | - Wei Zhu
- Department of Oncology, Hospital of Chinese Medicine of Changxing County, Huzhou, China
| | - Bingchen Wu
- Department of Oncology, Hospital of Chinese Medicine of Changxing County, Huzhou, China
| | - Huiyin Lan
- Department of Thoracic Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine, Chinese Academy of Sciences, Hangzhou, China
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Zhao X, Yue D, Qian J, Zhang L, Song J, Zhang B, Zhang C, Sun L, Ma Y, Zhang H, Wang C. Case Report: Sarcoid-Like Reactions and Tertiary Lymphoid Structures Following Dual Checkpoint Inhibition in a Patient with Early-Stage Lung Adenocarcinoma. Front Immunol 2022; 13:794217. [PMID: 35173719 PMCID: PMC8841621 DOI: 10.3389/fimmu.2022.794217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/11/2022] [Indexed: 01/15/2023] Open
Abstract
Immune checkpoint inhibitor-induced sarcoid-like reactions and tertiary lymphoid structures (TLSs) are increasingly recognized but rarely reported in the same patient. We report a patient with lung adenocarcinoma who displayed sarcoid-like reactions in intrathoracic lymph nodes and tertiary lymphoid structures in surgical tumor after neoadjuvant therapy with nivolumab plus ipilimumab. Pathological examination revealed 50% residual tumor cells after treatment, and the CT evaluation of the primary tumor showed a stable disease. The patient experienced a recurrence eight months after surgery. To identify immune correlates of the limited response to immunotherapy, we conducted genomic and transcriptional assays, multiplex immunoassay, and multiplex immunohistochemistry on the pre- and post-immunotherapy tumor, lymph node, and plasma samples. TP53 R181C, KRAS G12C and SMAD4 R361H were identified as driver mutations of the tumor. In addition to abundant infiltrated lymphocytes, immunotherapy induced high levels of inhibitory components in post-treatment tissue samples, especially the FOXP3+ regulatory T cells in tumor and PD-L1 expression in the lymph node. Despite abundant TLSs in the post-treatment tumor, most TLSs were immature. Moreover, increasing levels of circulating checkpoint proteins BTLA, TIM-3, LAG-3, PD-1, PD-L1, and CTLA4 were observed during immunotherapy. Collectively, our observations revealed that high levels of immunosuppressive molecules in tumor, lymph nodes and/or in peripheral blood might indicate poor outcomes after immunotherapy, even in the setting of a patient with concurrent sarcoid-like reactions and tertiary lymphoid structures.
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Affiliation(s)
- Xiaoliang Zhao
- Tianjin Medical University Cancer Institute and Hospital, Tianjin Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Dongsheng Yue
- Tianjin Medical University Cancer Institute and Hospital, Tianjin Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Juanjuan Qian
- Department of Medicine, Genecast Biotechnology Co., Ltd, Wuxi, China
| | - Lei Zhang
- Department of Medicine, Genecast Biotechnology Co., Ltd, Wuxi, China
| | - Jin Song
- Department of Medicine, Genecast Biotechnology Co., Ltd, Wuxi, China
| | - Bin Zhang
- Tianjin Medical University Cancer Institute and Hospital, Tianjin Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Chunmei Zhang
- Department of Medicine, Genecast Biotechnology Co., Ltd, Wuxi, China
| | - Leina Sun
- Tianjin Medical University Cancer Institute and Hospital, Tianjin Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Yuchen Ma
- Tianjin Medical University Cancer Institute and Hospital, Tianjin Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
| | - Henghui Zhang
- Beijing Shijitan Hospital, and School of Oncology, Capital Medical University, Beijing, China
- *Correspondence: Changli Wang, ; Henghui Zhang,
| | - Changli Wang
- Tianjin Medical University Cancer Institute and Hospital, Tianjin Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin, China
- *Correspondence: Changli Wang, ; Henghui Zhang,
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Uppal NN, Workeneh BT, Rondon-Berrios H, Jhaveri KD. Electrolyte and Acid-Base Disorders associated with Cancer Immunotherapy. Clin J Am Soc Nephrol 2022; 17:922-933. [PMID: 35063968 PMCID: PMC9269647 DOI: 10.2215/cjn.14671121] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Novel immunotherapy drugs have changed the landscape of cancer medicine. Immune checkpoint inhibitors and chimeric antigen receptor T cells are being used and investigated in almost all solid cancers. Immune-related adverse events have been associated with immunotherapies. Acute kidney injury has been the most commonly associated kidney adverse event. In this review, we showcase the several associated electrolyte disorders seen with immunotherapy. Immune checkpoint inhibitors can lead to hyponatremia by several mechanisms, with the syndrome of inappropriate antidiuresis being the most common. Endocrine causes of hyponatremia are rare. Hypokalemia is not uncommon and is associated with both proximal and distal renal tubular acidosis. Hypercalcemia associated with immune checkpoint inhibitors has led to some interesting observations including immune checkpoint inhibitor-induced parathyroid hormone - related peptide production, sarcoid-like granulomas, and hyper-progression of the disease. Hypocalcemia and hyperphosphatemia may be seen with immune checkpoint inhibitor-induced tumor lysis syndrome. Chimeric antigen receptor T cell therapy-associated electrolyte disorders are also common. This is associated chiefly with hyponatremia, although other electrolyte abnormalities can occur. Early recognition and prompt diagnosis may help providers manage the mechanistically varied and novel electrolyte disorders associated with immunotherapy.
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Affiliation(s)
- Nupur N. Uppal
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
| | - Biruh T. Workeneh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
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Pulmonary Toxicities of Immunotherapy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1342:357-375. [PMID: 34972974 DOI: 10.1007/978-3-030-79308-1_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Immune checkpoint inhibitors are a form of immunotherapy that are increasingly being used in a wide variety of cancers. Immune-related adverse events (irAEs) pose a major challenge in the treatment of cancer patients. Pneumonitis, the most common lung irAE, can cause significant disruptions in the treatment of cancer and may be life-threatening. The goal of this chapter is to instruct readers on the incidence and clinical manifestations of pneumonitis and to offer guidance in the evaluation and treatment of patients with pneumonitis.
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Shi Y, Li J, Chen M, Liu H, Ma D, Lin Y, Wang M, Xu Y. Sarcoidosis-like reaction after neoadjuvant pembrolizumab combined with chemotherapy mimicking disease progression of NSCLC induced encouraging discovery of pathological complete response. Thorac Cancer 2021; 12:3433-3436. [PMID: 34761878 PMCID: PMC8671890 DOI: 10.1111/1759-7714.14228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 01/22/2023] Open
Abstract
Neoadjuvant chemoimmunotherapy has demonstrated improved efficacy and prognosis in stage IIa–IIIb patients with non‐small cell lung cancer (NSCLC). Drug‐induced sarcoidosis‐like reaction (DISR), an autoimmune reaction, has been reported as a type of immune‐related adverse event that may mimic disease progression. Here, we report the case of patient with NSCLC who developed DISR during neoadjuvant chemoimmunotherapy and finally achieved pathological complete response after surgery.
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Affiliation(s)
- Yuequan Shi
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ji Li
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Minjiang Chen
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dongjie Ma
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuxiao Lin
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mengzhao Wang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yan Xu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Georgakopoulou VE, Garmpis N, Mermigkis D, Damaskos C, Chlapoutakis S, Mantzouranis K, Gkoufa A, Papageorgiou C, Garmpi A, Makrodimitri S, Diamantis E, Sklapani P, Trakas N, Tsiafaki X. Pulmonary adverse events due to immune checkpoint inhibitors: A literature review. Monaldi Arch Chest Dis 2021; 92. [PMID: 34634898 DOI: 10.4081/monaldi.2021.2008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/14/2021] [Indexed: 11/23/2022] Open
Abstract
Cancer immunotherapy aims to stimulate the immune system to fight against tumors, utilizing the presentation of molecules on the surface of the malignant cells that can be recognized by the antibodies of the immune system. Immune checkpoint inhibitors, a type of cancer immunotherapy, are broadly used in different types of cancer, improving patients' survival and quality of life. However, treatment with these agents causes immune-related toxicities affecting many organs. The most frequent pulmonary adverse event is pneumonitis representing a non-infective inflammation localized to the interstitium and alveoli. Other lung toxicities include airway disease, pulmonary vasculitis, sarcoid-like reactions, infections, pleural effusions, pulmonary nodules, diaphragm myositis and allergic bronchopulmonary aspergillosis. This review aims to summarize these pulmonary adverse events, underlining the significance of an optimal expeditious diagnosis and management.
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Affiliation(s)
| | - Nikolaos Garmpis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens.
| | | | - Christos Damaskos
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens.
| | | | | | - Aikaterini Gkoufa
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens.
| | | | - Anna Garmpi
- First Department of Propedeutic Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens.
| | | | - Evangelos Diamantis
- Unit of Endocrinology and Diabetes Center, Athens General Hospital ¨G. Gennimatas¨, Athens.
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Sachpekidis C, Kopp-Schneider A, Hassel JC, Dimitrakopoulou-Strauss A. Assessment of early metabolic progression in melanoma patients under immunotherapy: an 18F-FDG PET/CT study. EJNMMI Res 2021; 11:89. [PMID: 34495433 PMCID: PMC8426446 DOI: 10.1186/s13550-021-00832-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/01/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The usage of immune checkpoint inhibitors (ICIs) is the standard practice for the treatment of metastatic melanoma. However, a significant amount of patients show no response to immunotherapy, while issues on its reliable response interpretation exist. Aim of this study was to investigate the phenomenon of early disease progression in 2-deoxy-2-(18F)fluoro-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in melanoma patients treated with ICIs. METHODS Thirty-one patients under ICIs serially monitored with 18F-FDG PET/CT were enrolled. All patients exhibited progressive metabolic disease (PMD) after two ICIs' cycles according to the European Organization for Research and Treatment of Cancer (EORTC) criteria, and were characterized as unconfirmed PMD (uPMD). They were further followed with at least one PET/CT for either confirmation of PMD (cPMD) or demonstration of pseudoprogression remission. Patients were also evaluated with the PET Response Evaluation Criteria for Immunotherapy (PERCIMT). Moreover, in an attempt to investigate immune activation, the spleen to liver ratios (SLRmean, SLRmax) of 18F-FDG uptake were measured. RESULTS Median follow up was 69.7 months [64.6-NA]. According to EORTC, 26/31 patients with uPMD eventually showed cPMD (83.9%) and 5/31 patients showed pseudoprogression (16.1%). Patients with cPMD (n = 26) had a median OS of 10.9 months [8.5-NA], while those with pseudoprogression (n = 5) did not reach a median OS [40.9-NA]. Respectively, after application of PERCIMT, 2/5 patients of the pseudoprogression group were correctly classified as non-PMD, reducing the uPMD cohort to 29 patients; eventually, 26/29 patients demonstrated cPMD (89.7%) and 3/29 pseudoprogression (10.3%). One further patient with pseudoprogression exhibited transient, sarcoid-like, mediastinal/hilar lymphadenopathy, a known immune-related adverse event (irAE). Finally, patients eventually showing cPMD exhibited a significantly higher SLRmean than those showing pseudoprogression after two ICIs' cycles (p = 0.038). CONCLUSION PET/CT, performed already after administration of two ICIs' cycles, can identify the majority of non-responders in melanoma immunotherapy. In order to tackle however, the non-negligible phenomenon of pseudoprogression, another follow-up PET/CT, the usage of novel response criteria and vigilance over emergence of radiological irAEs are recommended. Moreover, the investigation of spleen glucose metabolism may offer further prognostic information in melanoma patients under ICIs.
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Affiliation(s)
- Christos Sachpekidis
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany.
| | | | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Antonia Dimitrakopoulou-Strauss
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany
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Chanson N, Ramos-Casals M, Pundole X, Suijkerbuik K, José de Barros E Silva M, Lidar M, Benesova K, Leipe J, Acar-Denizli N, Pradère P, Michot JM, Voisin AL, Suárez-Almazor ME, Radstake TRD, Fernandes Moça Trevisani V, Schulze-Koops H, Melin A, Robert C, Mariette X, Baughman RP, Lambotte O. Immune checkpoint inhibitor-associated sarcoidosis: A usually benign disease that does not require immunotherapy discontinuation. Eur J Cancer 2021; 158:208-216. [PMID: 34452793 DOI: 10.1016/j.ejca.2021.05.041] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/27/2021] [Accepted: 05/24/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To analyse the clinical patterns of sarcoidosis triggered by immune checkpoint inhibitors (ICIs) in patients with cancer. PATIENTS AND METHODS The ImmunoCancer International Registry is a big data-sharing multidisciplinary network from 18 countries dedicated to evaluating the clinical research of immune-related adverse events related to cancer immunotherapies. RESULTS We identified 32 patients with biopsy-proven sarcoidosis. Underlying cancer included mainly melanoma (n = 24). Cancer immunotherapy consisted of monotherapy in 19 cases (anti-PD-1 in 18 and ipilimumab in 1) or combined ipilimumab + nivolumab in 13. The time median interval between initiation of ICI and sarcoidosis diagnosis was 3 months (range, 2-29 months). The use of combined ICI was associated with a shorter delay in developing sarcoidosis symptoms. The disease was symptomatic in 19 (59%) cases with mostly cutaneous, respiratory and general symptoms. The organs involved included mainly the mediastinal lymph nodes (n = 32), the lungs (n = 11), the skin (n = 10) and the eyes (n = 5). Pulmonary computed tomography studies showed bilateral hilar lymphadenopathy in all cases. There was no severe manifestation. Specific systemic therapy was required in only 12 patients (37%): oral glucocorticoids in 9, and hydroxychloroquine in 3. ICIs were held in 25 patients (78%) and definitively discontinued in 18 (56%) patients. Seven patients continued ICI treatment with a second flare in one case. In six additional patients, an ICI was reintroduced with no harm, and sarcoidosis relapsed in one of them. CONCLUSION Our study shows that ICI-related sarcoidosis seems to have a specific profile, possibly more benign than that of idiopathic sarcoidosis, and does not necessarily imply ICI discontinuation.
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Affiliation(s)
- Noémie Chanson
- AP-HP.Université Paris-Saclay, Hôpital Bicêtre, Department of Internal Medicine and Clinical Immunology, Le Kremlin Bicêtre, France; Université Paris-Saclay; INSERM; CEA, Centre Immunology of Viral Infections and Autoimmune Diseases, IDMIT Department, IBFJ, Le Kremlin-Bicêtre, France
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain; Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain.
| | - Xerxes Pundole
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karijn Suijkerbuik
- Department of Medical Oncology, UMC Utrecht Cancer Center, Utrecht, the Netherlands
| | | | - Merav Lidar
- Rheumatology Unit, Sheba Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karolina Benesova
- Department of Internal Medicin and Rheumatology, Universitätsklinikum Heidelberg, Germany
| | - Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Medical Faculty Mannheim of the University Heidelberg, German
| | - Nihan Acar-Denizli
- Department of Statistics, Faculty of Science and Letters, Mimar Sinan Fine Arts University, Istanbul, Turkey
| | - Pauline Pradère
- Department of Thoracic Surgery, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Jean-Marie Michot
- Département D'Innovation Thérapeutique et D'Essais Précoces, Institut Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Anne-Laure Voisin
- Unité Fonctionnelle de Pharmacovigilance, Institut Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Maria E Suárez-Almazor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy R D Radstake
- Department of Medical Oncology, UMC Utrecht Cancer Center, Utrecht, the Netherlands
| | | | - Hendrik Schulze-Koops
- Department of Internal Medicin and Rheumatology, Universitätsklinikum Heidelberg, Germany
| | - Audrey Melin
- Department of Dermatology, Institut Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Caroline Robert
- Department of Dermatology, Institut Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Xavier Mariette
- Université Paris-Saclay; INSERM; CEA, Centre Immunology of Viral Infections and Autoimmune Diseases, IDMIT Department, IBFJ, Le Kremlin-Bicêtre, France; AP-HP.Université Paris-Saclay, Department of Rheumatology, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Robert P Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Olivier Lambotte
- AP-HP.Université Paris-Saclay, Hôpital Bicêtre, Department of Internal Medicine and Clinical Immunology, Le Kremlin Bicêtre, France; Université Paris-Saclay; INSERM; CEA, Centre Immunology of Viral Infections and Autoimmune Diseases, IDMIT Department, IBFJ, Le Kremlin-Bicêtre, France.
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Cabanié C, Ammari S, Hans S, Pobel C, Laparra A, Danlos FX, Chanson N, Dolidon S, Seban R, Voisin AL, Pautier P, Romano-Martin P, Even C, Baldini C, Besse B, Albiges L, Boutros C, Routier E, Balleyguier C, De Montpreville VT, Champiat S, Massard C, Robert C, Marabelle A, Mateus C, Lambotte O, Le Pavec J, Michot JM. Outcomes of patients with cancer and sarcoid-like granulomatosis associated with immune checkpoint inhibitors: A case-control study. Eur J Cancer 2021; 156:46-59. [PMID: 34425404 DOI: 10.1016/j.ejca.2021.07.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/11/2021] [Accepted: 07/14/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Sarcoid-like granulomatosis (SLG) reaction caused by immunotherapy remains poorly understood. This study aims to investigate the outcome of patients with cancer and SLG associated with immunotherapy. PATIENTS AND METHODS Between April 2016 and June 2020, 434 patients with immunological adverse events were screened from the ImmunoTOX assessment board of Gustave Roussy, an academic cancer centre in France. Among them, 28 patients had SLG associated with immunotherapy (SLG cohort) and 406 patients had other immunological adverse events (control cohort). Clinical characteristics and outcome of patients were compared from SLG and control cohort. RESULTS The SLG cohort consisted of 28 patients, 14 women and 14 men, with the median (range) age of 56.5 (28.7-75.3) years. Patients in the SLG cohort with sarcoidosis were asymptomatic (only radiographical finding) in 13 (46.4%) cases; otherwise, the most frequent symptoms were dyspnoea in 8 (28.6%) patients and cough in 5 (17.8%) patients. The computerised tomography scan found sarcoidosis localisations in mediastinal or peri-hilar thoracic lymph nodes in 26 (92.9%) patients, and lung parenchymal involvement was found in 14 (50.0%) patients. The radiographic Scadding stages for sarcoidosis classification were distributed in stages 0, I, II, III and IV in 2 patients (7.1%), 13 patients (46.4%), 11 patients (39.3%), 1 patient (3.6%) and 1 patient (3.6%), respectively. Compared with patients with other immunological toxicities (cohort control), patients with sarcoidosis presented most frequently with melanoma (75.0% versus 21.9% of patients; p < 0.001) and more often received combined therapies of anti-programmed cell death 1 plus anti-cytotoxic T-lymphocyte antigen 4 protein (46.4% versus 12.6% of patients; p = 0.002). Patients with sarcoidosis had an improved overall survival (OS); the median OS was not reached in the SLG cohort and 40.4 months in the control cohort, hazard ratio = 0.232 (95% confidence interval: 0.086-0.630) (p = 0.002). CONCLUSION Sarcoidosis-like reactions in patients receiving immunotherapy were reported as non-severe immunological reactions in most cases and were correlated with improved OS. SLG should not be misdiagnosed as tumour progression in patients receiving immunotherapy treatment for cancer.
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Affiliation(s)
- Charlotte Cabanié
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Samy Ammari
- Department of Radiology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France; Université Paris-Saclay, BIOMAPS, UMR1281, INSERM, CEA, CNRS, Paris, France
| | - Sophie Hans
- Department of Radiology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Cedric Pobel
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Ariane Laparra
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Francois-Xavier Danlos
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Noémie Chanson
- Department of Internal Medicine, AP-HP. Université Paris-Saclay, Hôpital Bicêtre, Kremlin Bicêtre, 94270, France
| | - Samuel Dolidon
- Department of Pneumology, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, 92350, France
| | - Romain Seban
- Department of Radiology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Anne-Laure Voisin
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Patricia Pautier
- Department of Medical Oncology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Patricia Romano-Martin
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Caroline Even
- Department of Medical Oncology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Capucine Baldini
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Benjamin Besse
- Department of Medical Oncology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Laurence Albiges
- Department of Medical Oncology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Celine Boutros
- Department of Medical Oncology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Emilie Routier
- Department of Medical Oncology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Corinne Balleyguier
- Department of Radiology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France; Université Paris-Saclay, BIOMAPS, UMR1281, INSERM, CEA, CNRS, Paris, France
| | | | - Stéphane Champiat
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Christophe Massard
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Caroline Robert
- Department of Medical Oncology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Aurélien Marabelle
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Christina Mateus
- Department of Medical Oncology, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France
| | - Olivier Lambotte
- Department of Internal Medicine, AP-HP. Université Paris-Saclay, Hôpital Bicêtre, Kremlin Bicêtre, 94270, France; Université Paris-Saclay, INSERM, CEA, Centre Immunology of Viral Infections and Autoimmune Diseases, IDMIT Department, IBFJ, Le Kremlin-Bicêtre, France
| | - Jérôme Le Pavec
- Department of Thoracic Surgery, Vascular Surgery, and Cardiopulmonary Transplantation, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Université Paris-Sud, Faculty of Medicine, Université Paris-Saclay, Le Kremlin Bicêtre, France; UMRS 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Jean-Marie Michot
- Département d'Innovation Thérapeutique et d'Essais Précoces, Institute Gustave Roussy, Université Paris-Saclay, Villejuif, F-94805, France.
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Nodal immune flare mimics nodal disease progression following neoadjuvant immune checkpoint inhibitors in non-small cell lung cancer. Nat Commun 2021; 12:5045. [PMID: 34413300 PMCID: PMC8376947 DOI: 10.1038/s41467-021-25188-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/27/2021] [Indexed: 01/07/2023] Open
Abstract
Radiographic imaging is the standard approach for evaluating the disease involvement of lymph nodes in patients with operable NSCLC although the impact of neoadjuvant immune checkpoint inhibitors (ICIs) on lymph nodes has not yet been characterized. Herein, we present an ad hoc analysis of the NEOSTAR trial (NCT03158129) where we observed a phenomenon we refer to as “nodal immune flare” (NIF) in which patients treated with neoadjuvant ICIs demonstrate radiologically abnormal nodes post-therapy that upon pathological evaluation are devoid of cancer and demonstrate de novo non-caseating granulomas. Abnormal lymph nodes are analyzed by computed tomography and 18F-fluorodeoxyglucose positron emission tomography/computer tomography to evaluate the size and the maximum standard uptake value post- and pre-therapy in NEOSTAR and an independent neoadjuvant chemotherapy cohort. NIF occurs in 16% (7/44) of patients treated with ICIs but in 0% (0/28) of patients after neoadjuvant chemotherapy. NIF is associated with an inflamed nodal immune microenvironment and with fecal abundance of genera belonging to the family Coriobacteriaceae of phylum Actinobacteria, but not with tumor responses or treatment-related toxicity. Our findings suggest that this apparent radiological cancer progression in lymph nodes may occur due to an inflammatory response after neoadjuvant immunotherapy, and such cases should be evaluated by pathological examination to distinguish NIF from true nodal progression and to ensure appropriate clinical treatment planning. Granulomatous/sarcoid-like lesions have been reported in patients treated with immune checkpoint inhibitors (ICIs). Here the authors report the occurrence of “nodal immune flare”, an apparent radiological cancer progression in the nodes characterized by the absence of cancer and the presence of non-caseating granulomas, in patients with non-small cell lung cancer following neoadjuvant ICI treatment.
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Kim SH, Singh R, Han C, Cho E, Kim YI, Lee DG, Kim YH, Kim SS, Shin DH, You HJ, Lee HW, Kwon BS, Choi BK. Chronic activation of 4-1BB signaling induces granuloma development in tumor-draining lymph nodes that is detrimental to subsequent CD8 + T cell responses. Cell Mol Immunol 2021; 18:1956-1968. [PMID: 32868911 PMCID: PMC8322392 DOI: 10.1038/s41423-020-00533-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/11/2020] [Indexed: 11/09/2022] Open
Abstract
The antitumor capabilities of agonistic anti-4-1BB mAbs have made them an attractive target for tumor immunotherapy. However, the adverse side effects associated with agonist antibodies have hindered their clinical development. Here, we aimed to study the immune-related adverse events of repeated doses and long-term use of agonistic anti-4-1BB mAbs. We show that chronic activation of 4-1BB signals induced the accumulation of IFN-γ-producing PD-1+CD8+ T cells in the secondary lymphoid organs of tumor-bearing mice by increasing the number of dividing CD8+ T cells, which was beneficial for suppressing tumor growth in the early phase of anti-4-1BB induction. However, repeated exposure to anti-4-1BB mAbs led to granuloma development in tumor-draining lymph nodes (TDLNs) of mice due to recruitment and accumulation of macrophages via the CD8+ T cell-IFN-γ axis. This was accompanied by excessive lymph node swelling, which impaired the sequential activation of CD8+ T cells. Our data provide insights into the immune-related adverse events of long-term agonist 4-1BB antibody dosing, which should be considered during the clinical development of immunomodulating therapy.
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Affiliation(s)
- Seon-Hee Kim
- Division of Tumor Immunology, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Rohit Singh
- Division of Tumor Immunology, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Chungyong Han
- Division of Tumor Immunology, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Eunjung Cho
- Division of Tumor Immunology, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Yu I Kim
- Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Don G Lee
- Biomedicine Production Branch, Program for Immunotherapy Research, Goyang, 10408, Republic of Korea
| | - Young H Kim
- Division of Tumor Immunology, National Cancer Center, Goyang, 10408, Republic of Korea
- Eutilex Institute for Biomedical Research, Eutilex, Co., Ltd., Seoul, 08594, Republic of Korea
| | - Sang Soo Kim
- Division of Convergence Technology, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Dong Hoon Shin
- Division of Translational Science, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Hye Jin You
- Division of Translational Science, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Hyeon-Woo Lee
- Institute of Oral Biology, School of Dentistry, Graduate School, Kyung Hee University, Seoul, 02447, Republic of Korea
| | - Byoung S Kwon
- Eutilex Institute for Biomedical Research, Eutilex, Co., Ltd., Seoul, 08594, Republic of Korea
- Department of Medicine, Tulane University Health Sciences Center, New Orleans, LA, 70112, USA
| | - Beom K Choi
- Biomedicine Production Branch, Program for Immunotherapy Research, Goyang, 10408, Republic of Korea.
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Lee JM, Tsuboi M, Brunelli A. Surgical perspective on neoadjuvant immunotherapy in non-small cell lung cancer. Ann Thorac Surg 2021; 114:1505-1515. [PMID: 34339672 DOI: 10.1016/j.athoracsur.2021.06.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/25/2021] [Accepted: 06/22/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND With a 5% improvement in 5-year overall survival achieved with current neoadjuvant or adjuvant chemotherapy, new treatments for resectable non-small cell lung cancer (NSCLC) are urgently needed. The use of immune checkpoint inhibitors (ICI) is established in metastatic NSCLC and is being evaluated in resectable NSCLC. METHODS Publications and conference databases and clinicaltrials.gov were searched for reports on clinical studies of neoadjuvant immunotherapy in patients with early resectable NSCLC. RESULTS Potential advantages of neoadjuvant ICI include earlier treatment of micrometastatic disease; activation of a broader, potentially durable immune response by the whole tumor and associated lymph nodes; and pathologic assessment of neoadjuvant treatment response, which may guide adjuvant therapy. Surgical considerations include delays to surgery, potential disease progression preventing curative resection, and perioperative morbidity and mortality. Surrogate endpoints of efficacy (pathologic complete response, major pathologic response) and biomarkers predictive of outcome (programmed death ligand 1 expression, tumor mutational burden and circulating tumor DNA) can accelerate clinical trial completion and early-stage treatment development; their application in neoadjuvant ICI studies in NSCLC is reviewed. CONCLUSIONS Phase 2 trials of neoadjuvant ICI alone or with chemotherapy showed encouraging safety and efficacy in patients with resectable NSCLC, warranting the ongoing phase 3 studies of neoadjuvant immunotherapy plus chemotherapy. Preoperative and intraoperative unresectability following neoadjuvant ICI appear comparable to neoadjuvant chemotherapy. To help thoracic surgeons and medical oncologists to distinguish amongst ICI beyond efficacy as phase 3 data emerge, surgery-related endpoints for perioperative morbidity, mortality, and complexity should be defined, standardized, incorporated into trial designs, and reported.
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Affiliation(s)
- Jay M Lee
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA, Division of Thoracic Surgery.
| | - Masahiro Tsuboi
- National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan Division of Thoracic Surgery, Department of Thoracic Oncology
| | - Alessandro Brunelli
- University of Leeds and St. James's University Hospital, Leeds, UK, Department of Thoracic Surgery
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Abstract
PURPOSE OF REVIEW Sarcoidosis is a complex granulomatous disease of unknown cause. Several drug categories are able to induce a systemic granulomatous indistinguishable from sarcoidosis, known as drug-induced sarcoidosis-like reaction (DISR). This granulomatous inflammation can resolve if the medication is discontinued. In this review, we discuss recent literature on medication associated with DISR, possible pathophysiology, clinical features, and treatment. RECENT FINDINGS Recently, increasing reports on DISR have expanded the list of drugs associated with the systemic granulomatous eruption. Most reported drugs can be categorized as combination antiretroviral therapy, tumor necrosis factor-α antagonist, interferons, and immune checkpoint inhibitors, but reports on other drugs are also published. The proposed mechanism is enhancement of the aberrant immune response which results in systemic granuloma formation. It is currently not possible to know whether DISR represents a separate entity or is a triggered but 'true' sarcoidosis.As DISRs may cause minimal symptoms, treatment is not always necessary and the benefits of continuing the offending drug should be weighed against clinical symptoms and organ dysfunction. Treatment may involve immunosuppressive medication that is used for sarcoidosis treatment. SUMMARY In this article, we review recent insights in DISR: associated drug categories, clinical presentation, diagnosis, and treatment. Additionally, we discuss possible mechanisms of DISR which can add to our knowledge of sarcoidosis pathophysiology.
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Sakellariou S, Zouki DN, Ziogas DC, Pouloudi D, Gogas H, Delladetsima I. Granulomatous colitis in a patient with metastatic melanoma under immunotherapy: a case report and literature review. BMC Gastroenterol 2021; 21:227. [PMID: 34011268 PMCID: PMC8136206 DOI: 10.1186/s12876-021-01812-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 05/11/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICPIs) have changed the way advanced malignancies are currently confronted, improving cancer patients' outcomes but also generating distinct immune-related (ir) adverse events. ICPIs-induced colitis is a common complication showing different clinical and histological manifestations. In the literature review, 14 cases with ICPIs related colon granulomas have been reported in 5 studies with either limited or unavailable information regarding histology. Granulomatous reactions can be mistakenly perceived as disease recurrence or progression. Better understanding and identification of this infrequent histological display can help to avoid misdiagnosis and mismanagement. CASE PRESENTATION A 63-year-old female patient with metastatic melanoma was admitted to the hospital with symptoms of nausea, persistent diarrhea and shivering fever under consecutive treatments with ICPIs, initially pembrolizumab and subsequently ipilimumab. Sigmoidoscopy was performed revealing mucosal edema, hyperemia and erosions of the rectum and sigmoid colon. Histological evaluation of sigmoid colon mucosa biopsies revealed an unusual colitis pattern characterized by multiple intracryptal granulomas attributed to ICPIs therapy. Steroids were administered and the patient recovered. ICPIs treatment was discontinued. The patient was subsequently treated with chemotherapy but follow up radiology showed disease progression. A re-challenge with another ICPI regimen was decided and the patient is currently under immunotherapy with stable disease regarding melanoma status and without any sign of colitis recurrence. CONCLUSIONS The present report provides detailed histological description of a distinctive ICPIs-induced granulomatous colitis and highlights the need for awareness of the distinct adverse events and reaction patterns in the context of immunotherapy.
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Affiliation(s)
- Stratigoula Sakellariou
- First Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75, Mikras Asias street, 11527, Athens, Greece.
| | - Dionysia N Zouki
- First Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75, Mikras Asias street, 11527, Athens, Greece
| | - Dimitrios C Ziogas
- First Department of Internal Medicine, Laiko General Hospital School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Despoina Pouloudi
- First Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75, Mikras Asias street, 11527, Athens, Greece
| | - Helen Gogas
- First Department of Internal Medicine, Laiko General Hospital School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Delladetsima
- First Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75, Mikras Asias street, 11527, Athens, Greece
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Curry JL, Chon SY, Marques-Piubelli ML, Chu EY. Cutaneous Toxicities in the Setting of Immune Checkpoint Blockade:: The Era of Oncodermatopathology. Surg Pathol Clin 2021; 14:209-224. [PMID: 34023101 DOI: 10.1016/j.path.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Advancements in cancer therapy with monoclonal immune checkpoint antibody blockade have impacted the practice of all medical specialties. Cutaneous immune-related adverse events (irAEs) are a frequent, unintended, off-target consequence of immune checkpoint inhibitor (ICI) therapy that have ushered in the era of oncodermatopathology. Knowledge of the diverse morphologic types of cutaneous irAEs from ICI therapy allows further classification of cutaneous irAEs according to major histopathologic reaction patterns. Early studies suggest that immune mechanisms of lichenoid dermatitis irAE, psoriasiform dermatitis irAE, and bullous pemphigoid irAE show some similarities and differences from their histopathologic counterparts not associated with ICI therapy.
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Affiliation(s)
- Jonathan L Curry
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Susan Y Chon
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mario L Marques-Piubelli
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Emily Y Chu
- Department of Dermatology, The University of Pennsylvania, Philadelphia, PA 19104, USA
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Immune-Related Erythema Nodosum Mimicking in Transit Melanoma Metastasis on [18F]-FDG PET/CT. Diagnostics (Basel) 2021; 11:diagnostics11050747. [PMID: 33922013 PMCID: PMC8143543 DOI: 10.3390/diagnostics11050747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/13/2021] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
Abstract
Early detection of immune-related adverse events (irAEs) with immune checkpoint inhibitors (ICIs) is crucial, particularly when these are likely to mimic tumor progression, as well as sarcoid-like reactions. Here, we report the case of a 68-year woman, with a history of four primary cutaneous melanomas (thickest lesion with BRAF mutation removed from the left axilla 2 years before), who was diagnosed with BRAF V600E-mutant metastatic melanoma and treated by ICI targeting the PD-1 receptor. Follow-up whole-body positron emission tomography/computed tomography (PET/CT) using 18F-fluorodeoxyglucose ([18F]-FDG) was performed at 15 months, and FDG-avid subcutaneous nodules on her legs were detected. A biopsy from a lesion on her right leg was obtained, and histology strongly suggested erythema nodosum. Given the isolated nature of these lesions, the normal serum Angiotensin-Converting Enzyme and the context of ICI, an immune-related sarcoid-like reaction was retained as the most likely diagnosis. Recent literature in immune-oncology suggests that erythema nodosum could be directly related to ICI(s). Although erythema nodosum is a rare occurrence with imaging features overlapping with malignancy, it should be considered in the differential diagnosis of suspicious in-transit metastasis, especially when the patient is treated with ICIs and when lesions follow a bilateral distribution. In conclusion, nuclear medicine physicians should keep in mind this irAE when interpreting PET/CT scans in clinical practice in order to avoid false-positive findings.
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Yasin H, Yadala V, Khan NAJ, Graffeo V, Denning K, Lebowicz Y. Immunotherapy-Induced Sarcoid-Like Reaction: A Shrewd Imitator. J Investig Med High Impact Case Rep 2021; 9:23247096211009400. [PMID: 33847154 PMCID: PMC8059040 DOI: 10.1177/23247096211009400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 40-year-old male with a right-sided neck mass was diagnosed with metastatic melanoma. A repeat positron-emission tomography after treatment with combination immunotherapy demonstrated increased hypermetabolic activity in the right supraclavicular, hilar, and mediastinal regions. Immunotherapy was discontinued and a BRAF/MEK inhibitor combination was started. Repeat imaging showed a decrease in size of the neck mass; however, hilar and mediastinal lymph nodes increased in size. A fine needle aspiration of mediastinal lymph nodes was consistent with a granulomatous process. A diagnosis of a sarcoid-like reaction (SLR) was made, and he was started on steroids. A follow-up positron emission tomography showed decreased hilar and mediastinal lymph node hypermetabolic activity. We, therefore, report this rare case of immunotherapy-induced SLR to the expanding literature on immunotherapy-related adverse effects and would like to highlight that SLR can occur in conjunction with disease progression making it challenging to distinguish between the two.
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Morales-Neira D. It's elemental! Siliceous diatom frustules producing sarcoid-like granulomas in the subcutis. J Cutan Pathol 2021; 48:795-801. [PMID: 33600017 DOI: 10.1111/cup.13991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Abstract
Silica granulomas have been described on the skin and are rare; however, this is the first report of a sarcoid-like granulomatous reaction because of siliceous diatom frustules in the subcutis, making this an unprecedented case. A 41-year-old female presented with a subcutaneous nodule on the right forearm clinically suggestive of cyst, foreign body, or lipoma. Excisional biopsy revealed subcutis with a sarcoid-like granulomatous reaction in a background of fibrosis, containing abundant semitransparent, exquisitely geometric particles, mildly refringent under polarized light, highlighted by phase contrast microscopy; special stains were negative for microorganisms. Definitive characterization of the peculiar fragments was accomplished by confocal laser microscopy, scanning electron microscopy, and energy dispersive X-ray spectroscopy, revealing them as diatom frustules made of silicon dioxide (SiO2 ) or silica. Diatoms are unicellular algae, their skeletons (frustules) made of silica have collected on the bottom of rivers, lakes, and oceans for thousands or millions of years and form what we know as diatomite or diatomaceous earth, which is widely used in different industries and easily available in the market. The mechanism whereby diatom frustules gained access to the patient's subcutis is enigmatic.
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McCord M, Lukas RV, Amidei C, Demars N, Gelb A, Buck J, Sachdev S, Feldman A, Tate M, Dixit K, Brat DJ, Jennings L, Horbinski C. Disappearance of MMR-deficient subclones after controlled IL-12 and PD-1 inhibition in a glioma patient. Neurooncol Adv 2021; 3:vdab045. [PMID: 34250480 PMCID: PMC8262637 DOI: 10.1093/noajnl/vdab045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Matthew McCord
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rimas V Lukas
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Christina Amidei
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Arnold Gelb
- Bristol-Myers Squibb, San Francisco, California, USA
| | - Jill Buck
- Ziopharm Oncology, Inc., Boston, Massachusetts, USA
| | - Sean Sachdev
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alexander Feldman
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Matthew Tate
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Karan Dixit
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniel J Brat
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lawrence Jennings
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Craig Horbinski
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Kim ST, Pundole X, Dadu R, Lambotte O, Ramos-Casals M, Suarez-Almazor ME. Use of immune checkpoint inhibitors in cancer patients with pre-existing sarcoidosis. Immunotherapy 2021; 13:465-475. [PMID: 33641345 DOI: 10.2217/imt-2020-0272] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Aim: To evaluate adverse events in cancer patients with pre-existing sarcoidosis receiving immune checkpoint inhibitors (ICIs). Patients & methods: We retrospectively reviewed cancer patients with sarcoidosis who underwent treatment with ICI to determine frequency of sarcoidosis flares. Results: 32 patients with sarcoidosis received ICIs The median time to ICI initiation was 7 years (range: 1 month to 51 years). One patient (3%) with a 20-year remote history of sarcoidosis developed a clinically symptomatic exacerbation after three doses of atezolizumab, with hilar lymphadenopathy, subcutaneous nodules, arthritis and uveitis. Atezolizumab was discontinued and prednisone initiated. She had a fluctuating course with two additional flares. Conclusion: Frequency of flares in patients with a remote history of sarcoidosis who receive ICIs is low.
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Affiliation(s)
- Sang T Kim
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xerxes Pundole
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ramona Dadu
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Olivier Lambotte
- AP-HP. Université Paris-Saclay, Hôpital Bicêtre Department of Internal Medicine & Clinical Immunology, Le Kremlin Bicêtre, France.,Université Paris-Saclay; INSERM; CEA, Centre Immunology of Viral Infections & Autoimmune Diseases, IDMIT Department, IBFJ, Le Kremlin-Bicêtre, France
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.,Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Maria E Suarez-Almazor
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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