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Xu Z, Li H, Yu X, Luo J, Zhang Z. Clinical characterization of hemophagocytic lymphohistiocytosis caused by immune checkpoint inhibitors: a review of published cases. Hematology 2024; 29:2340144. [PMID: 38606818 DOI: 10.1080/16078454.2024.2340144] [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: 11/08/2023] [Accepted: 04/02/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVE An association exists between immune checkpoint inhibitors and hemophagocytic lymphohistiocytosis (HLH). Therefore, the main objective of this study was to collect data on this rare but potentially life-threatening immune-related adverse reaction to identify the medications that cause it, the clinical characteristics, and effective treatments. METHODS Literature in English and Chinese on immune checkpoint inhibitors causing HLH published from August 2014 to March 2024 was analyzed. Immune checkpoint inhibitors, immunotherapy, anti-PD-1, PD-L1 inhibitors, HLH, hemophagocytic lymphohistiocytosis, hemophagocytic syndrome keywords were used to find the literature on China Knowledge Network, Wanfang, PubMed and Emabase Databases. RESULTS AND DISCUSSION Twenty-four studies were included, with a total of 27 patients (18 males and 9 females) with a mean age of 58 years (range 26-86). The mean time to the onset of symptoms was 10.3 weeks (7 days-14 months). The main clinical characteristics were fever, cytopenia, splenomegaly, methemoglobinemia, hypofibrinogenemia, and bone marrow biopsy showed phagocytosis. Twenty-two patients improved after the treatment with steroids, cytokine blocking therapy and symptomatic treatment, four patients died, and one patient was not described. CONCLUSION HLH should be not underestimated as a potentially serious adverse effect of immune checkpoint inhibitors since appropriate treatments may save the life of patients.
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Affiliation(s)
- Zhiya Xu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Huilan Li
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Xinyi Yu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Jia Luo
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Zanling Zhang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People's Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People's Republic of China
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Jing D, Liu J, Qin D, Lin J, Li T, Li Y, Duan M. Obeticholic acid ameliorates sepsis-induced renal mitochondrial damage by inhibiting the NF-κb signaling pathway. Ren Fail 2024; 46:2368090. [PMID: 39108162 PMCID: PMC11308967 DOI: 10.1080/0886022x.2024.2368090] [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: 02/26/2024] [Revised: 05/19/2024] [Accepted: 06/10/2024] [Indexed: 08/10/2024] Open
Abstract
Acute kidney injury (AKI), a common complication of sepsis, might be caused by overactivated inflammation, mitochondrial damage, and oxidative stress. However, the mechanisms underlying sepsis-induced AKI (SAKI) have not been fully elucidated, and there is a lack of effective therapies for AKI. To this end, this study aimed to investigate whether obeticholic acid (OCA) has a renoprotective effect on SAKI and to explore its mechanism of action. Through bioinformatics analysis, our study confirmed that the mitochondria might be a critical target for the treatment of SAKI. Thus, a septic rat model was established by cecal ligation puncture (CLP) surgery. Our results showed an evoked inflammatory response via the NF-κB signaling pathway and NLRP3 inflammasome activation in septic rats, which led to mitochondrial damage and oxidative stress. OCA, an Farnesoid X Receptor (FXR) agonist, has shown anti-inflammatory effects in numerous studies. However, the effects of OCA on SAKI remain unclear. In this study, we revealed that pretreatment with OCA can inhibit the inflammatory response by reducing the synthesis of proinflammatory factors (such as IL-1β and NLRP3) via blocking NF-κB and alleviating mitochondrial damage and oxidative stress in the septic rat model. Overall, this study provides insight into the excessive inflammation-induced SAKI caused by mitochondrial damage and evidence for the potential use of OCA in SAKI treatment.
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Affiliation(s)
- Danyang Jing
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jingfeng Liu
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Da Qin
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jin Lin
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Tian Li
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yu Li
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Guo AJ, Deng QY, Dong P, Zhou L, Shi L. Biomarkers associated with immune-related adverse events induced by immune checkpoint inhibitors. World J Clin Oncol 2024; 15:1002-1020. [DOI: 10.5306/wjco.v15.i8.1002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/13/2024] [Accepted: 06/21/2024] [Indexed: 08/16/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) constitute a pivotal class of immunotherapeutic drugs in cancer treatment. However, their widespread clinical application has led to a notable surge in immune-related adverse events (irAEs), significantly affecting the efficacy and survival rates of patients undergoing ICI therapy. While conventional hematological and imaging tests are adept at detecting organ-specific toxicities, distinguishing adverse reactions from those induced by viruses, bacteria, or immune diseases remains a formidable challenge. Consequently, there exists an urgent imperative for reliable biomarkers capable of accurately predicting or diagnosing irAEs. Thus, a thorough review of existing studies on irAEs biomarkers is indispensable. Our review commences by providing a succinct overview of major irAEs, followed by a comprehensive summary of irAEs biomarkers across various dimensions. Furthermore, we delve into innovative methodologies such as machine learning, single-cell RNA sequencing, multiomics analysis, and gut microbiota profiling to identify novel, robust biomarkers that can facilitate precise irAEs diagnosis or prediction. Lastly, this review furnishes a concise exposition of irAEs mechanisms to augment understanding of irAEs prediction, diagnosis, and treatment strategies.
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Affiliation(s)
- An-Jie Guo
- School of Life Sciences, Chongqing University, Chongqing 400044, China
| | - Qing-Yuan Deng
- School of Life Sciences, Chongqing University, Chongqing 400044, China
| | - Pan Dong
- School of Life Sciences, Chongqing University, Chongqing 400044, China
| | - Lian Zhou
- Head and Neck Cancer Center, Chongqing University Cancer Hospital, Chongqing 400000, China
| | - Lei Shi
- School of Life Sciences, Chongqing University, Chongqing 400044, China
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4
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Abdel-Wahab N, Suarez-Almazor ME. Rheumatic adverse events of immune checkpoint inhibitors in cancer immunotherapy. Expert Rev Clin Immunol 2024; 20:873-893. [PMID: 38400840 DOI: 10.1080/1744666x.2024.2323966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/19/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION The advent of immune checkpoint inhibitors (ICIs) in cancer treatment has marked a transformative era, albeit tempered by immune-related adverse events (irAEs), including those impacting the musculoskeletal system. The lack of precise epidemiologic data on rheumatic irAEs is attributed to factors such as potential underrecognition, underreporting in clinical trials, and the tendency to overlook manifestations without immediate life-threatening implications, further complicating the determination of accurate incidence rates, while the complete understanding of the mechanisms driving rheumatic irAEs remains elusive. AREAS COVERED This literature review comprehensively examines rheumatic irAEs in cancer patients undergoing ICI therapy, encompassing epidemiology, risk factors, mechanisms, clinical manifestations, and current management guidance for prevalent conditions such as inflammatory arthritis, polymyalgia rheumatica, and myositis. Less frequent rheumatic and musculoskeletal irAEs are also explored, alongside insights into ongoing clinical trials testing therapeutic and preventive strategies for irAEs. A thorough literature search on Medline and the National Cancer Institute Clinical Trials Database was conducted up to October 2023 to compile relevant information. EXPERT OPINION In light of the evolving landscape of cancer immunotherapy, there is a compelling need for prospective longitudinal studies to enhance understanding and inform clinical management strategies for rheumatic irAEs.
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Affiliation(s)
- Noha Abdel-Wahab
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine; and Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Rheumatology and Rehabilitation, Assiut University Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Maria E Suarez-Almazor
- Department of Health Services Research; and Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Hayashi Y, Tsukada M, Shinoda D, Matsui M, Iwama K, Kajiwara K, Yasuji K. Successful Treatment of Steroid-Refractory Immune Thrombocytopenia in a Patient Developing Multiple Myeloma While on Immune Checkpoint Inhibitor Therapy for Lung Cancer: A Case Report. J Blood Med 2024; 15:285-290. [PMID: 38919949 PMCID: PMC11198016 DOI: 10.2147/jbm.s468921] [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: 03/15/2024] [Accepted: 06/12/2024] [Indexed: 06/27/2024] Open
Abstract
Immune checkpoint inhibitor-related thrombocytopenia (irTCP) is a relatively rare immune-related adverse event (irAE); however, overall survival may worsen when it occurs. Prolonged use of high-dose steroids can diminish the effectiveness of immune checkpoint inhibitor (ICI) therapy on the primary disease because of T lymphocyte suppression, thus early tapering is necessary. We experienced a rare case of a 79-year-old male who concurrently developed irTCP and multiple myeloma (MM) during treatment with ICIs for lung adenocarcinoma. The patient exhibited severe thrombocytopenia and elevated serum IgA levels. Based on various tests, we diagnosed MM and irTCP. Despite administering the standard bortezomib plus dexamethasone (Bd therapy) treatment for MM, there was no response and the irTCP was steroid-resistant. Consequently, we administered a regimen including daratumumab (DPd therapy) for steroid-resistant irTCP and refractory MM, which resulted in a response. As a result, we were able to avoid prolonged use of high-dose steroids and the patient is stable without exacerbation of lung adenocarcinoma for 1 year and 5 months after the onset of MM. To our knowledge, there are no cases of MM developing during ICI treatment and this is the first case report in which daratumumab was effective for the treatment of irTCP.
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Affiliation(s)
- Yudai Hayashi
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Fuchu City, Tokyo, Japan
| | - Masao Tsukada
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Fuchu City, Tokyo, Japan
| | - Daisuke Shinoda
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Fuchu City, Tokyo, Japan
| | - Marina Matsui
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Fuchu City, Tokyo, Japan
| | - Kanichi Iwama
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Fuchu City, Tokyo, Japan
| | - Koichi Kajiwara
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Fuchu City, Tokyo, Japan
| | - Kozai Yasuji
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Fuchu City, Tokyo, Japan
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Patton L, Monteith B, Heffernan P, Herzinger T, Wilson BE. Hemophagocytic lymphohistiocytosis/cytokine release syndrome secondary to neoadjuvant pembrolizumab for triple-negative breast cancer: a case study. Front Oncol 2024; 14:1394543. [PMID: 38919527 PMCID: PMC11196757 DOI: 10.3389/fonc.2024.1394543] [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: 03/01/2024] [Accepted: 05/10/2024] [Indexed: 06/27/2024] Open
Abstract
As indications for immune checkpoint inhibitors for breast cancer continue to expand, rare toxicities will emerge that require careful consideration and multidisciplinary management. We report the case of a 40-year-old female receiving neoadjuvant pembrolizumab and chemotherapy for locally advanced triple-negative breast cancer who developed cytokine release syndrome (CRS)/hemophagocytic lymphohistiocytosis (HLH). CRS/HLH secondary to pembrolizumab are scarcely documented in the literature and, to our knowledge, have never been reported in the context of neoadjuvant treatment for breast cancer.
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Affiliation(s)
- Laura Patton
- Department of Oncology, Queen’s University, Kingston, ON, Canada
| | - Bethany Monteith
- Department of Haematology, Queen’s University, Kingston, ON, Canada
| | - Paul Heffernan
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada
| | - Thomas Herzinger
- Division of Dermatology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Brooke E. Wilson
- Department of Oncology, Queen’s University, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, ON, Canada
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Geusens D, Dierickx D, Carton S, Van Cutsem E, Dekervel J. Immunotherapy Rechallenge After Checkpoint Inhibitor Induced Hemophagocytic Lymphohistiocytosis: A Case Report and Literature Review. Clin Colorectal Cancer 2024; 23:194-197. [PMID: 38519390 DOI: 10.1016/j.clcc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 01/11/2024] [Accepted: 01/16/2024] [Indexed: 03/24/2024]
Affiliation(s)
- Dorien Geusens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Belgium
| | - Saskia Carton
- Department of Gastroenterology and Hepatology, Imelda Hospital, Imeldalaan 9, 2820 Bonheiden, Belgium
| | - Eric Van Cutsem
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Jeroen Dekervel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
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8
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Gao L, Liu Y, Liu J, Li J, Li H, Liu Y, Meng F, Du X, Gao Y, Li J, Qin FX. Proton pump inhibitors stabilize the expression of PD-L1 on cell membrane depending on the phosphorylation of GSK3β. Cancer Med 2024; 13:e7083. [PMID: 38752436 PMCID: PMC11097254 DOI: 10.1002/cam4.7083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Preclinical and clinical evidence indicates that proton pump inhibitors (PPIs) may indirectly diminish the microbiome diversity, thereby reducing the effectiveness of immune checkpoint inhibitors (ICIs). Conversely, recent publications have shown that PPIs could potentially enhance the response to ICIs. The precise mechanism through which PPIs modulate the ICIs remains unclear. In this study, we discovered a novel molecular function of PPIs in regulating immune invasion, specifically through inducing PD-L1 translocation in various tumor cells. METHODS C57BL/6 mice subcutaneous transplantation model is used to verify the potential efficacy of PPIs and PD-L1 antibody. Western blotting analysis and phosphorylated chip are used to verify the alteration of PD-L1-related pathways after being treated with PPIs. The related gene expression is performed by qRT-PCR and luciferase reporter analysis. We also collected 60 clinical patients diagnosed with esophageal cancer or reflux esophagitis and then detected the expression of PD-L1 in the tissue samples by immunohistochemistry. RESULTS We observed that the IC50 of tumor cells in response to PPIs was significantly higher than that of normal epithelial cells. PPIs significantly increased the expression of PD-L1 on cell membrane at clinically relevant concentrations. Furthermore, pre-treatment with PPIs appeared to synergize the efficiency of anti-PD-L1 antibodies in mouse models. However, PPI administration did not alter the transcription or total protein level of PD-L1 in multiple tumor cells. Using a phosphorylated protein chip, we identified that PPIs enhanced the phosphorylation of GSK3β, then leading to PD-L1 protein translocation to the cell membranes. The capacity of PPIs to upregulate PD-L1 was negated following GSK3β knockout. Furthermore, our clinical data showed that the PPIs use resulted in increased PD-L1 expression in esophageal cancer patients. CONCLUSION We mainly address a significant and novel mechanism that the usage of PPIs could directly induce the expression of PD-L1 by inducing GSK3β phosphorylation and facilitate primary tumor progression and metastasis.
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Grants
- the Natural Science Foundation in Anhui Province (No. 2208085MH264, 2308085QH284, 2308085MH243)
- China Primary Health Care Foundation (No. MTP2022A015) and the Project Supported by Anhui Medical University (2021xkj138), Post-doctoral scientific research project of Anhui Province(No. 2022B609)
- National Natural Science Foundation of China (No. 81973983, 82270015, 82100017, 82302577, 82304209)
- 2021lcxk006 the joint construction project of clinical medicine university and hospital
- Anhui Province scientific research planning project (2023AH010083, 2023AH053282)
- National Natural Science Foundation of China (No. 81973983, 82270015, 82100017, 82302577, 82304209)
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Affiliation(s)
- Long Gao
- Department of Infectious DiseaseThe First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Yuan Liu
- Market Supervision Administration of Xiangcheng DistrictSuzhouChina
| | - Jiaying Liu
- Department of Infectious DiseaseThe First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Jiali Li
- Department of Infectious DiseaseThe First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Haotian Li
- Department of Infectious DiseaseThe First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Yanyan Liu
- Department of Infectious DiseaseThe First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Fang Meng
- National Key Laboratory of Immunity and InflammationSuzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences and Peking Union Medical CollegeSuzhouJiangsuChina
- Key Laboratory of Synthetic Biology Regulatory ElementsSuzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences and Peking Union Medical CollegeSuzhouJiangsuChina
| | - Xiaohong Du
- National Key Laboratory of Immunity and InflammationSuzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences and Peking Union Medical CollegeSuzhouJiangsuChina
- Key Laboratory of Synthetic Biology Regulatory ElementsSuzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences and Peking Union Medical CollegeSuzhouJiangsuChina
- Suzhou Hospital, Affiliated Hospital of Medical SchoolNanjing UniversitySuzhouChina
| | - Yufeng Gao
- Department of Infectious DiseaseThe First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Jiabin Li
- Department of Infectious DiseaseThe First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - F. Xiao‐Feng Qin
- National Key Laboratory of Immunity and InflammationSuzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences and Peking Union Medical CollegeSuzhouJiangsuChina
- Key Laboratory of Synthetic Biology Regulatory ElementsSuzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences and Peking Union Medical CollegeSuzhouJiangsuChina
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Heynemann S, Vanguru V, Adelstein S, Kao S. Hemophagocytic lymphohistiocytosis (HLH) and cytokine release syndrome (CRS) in a patient with oncogene-addicted metastatic non-small cell lung cancer (NSCLC) following combination chemotherapy-immunotherapy. Asia Pac J Clin Oncol 2024; 20:315-318. [PMID: 36562695 DOI: 10.1111/ajco.13906] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 10/31/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are utilized in a variety of clinical settings for the management of patients with metastatic non-small cell lung cancer (mNSCLC). While any organ may be subject to immune-related adverse events (irAEs) as a consequence of ICI therapy, hematological irAEs are uncommon. We describe a scenario involving a patient with oncogene-addicted mNSCLC who experienced the rare, life-threatening complication of hemophagocytic lymphohistiocytosis (HLH) and cytokine release syndrome following the receipt of the IMPower150 regimen (carboplatin/paclitaxel/atezolizumab/bevacizumab) after progression on initial tyrosine kinase inhibitor therapy. Malignancy-associated HLH, while previously described, is more typically associated with hematological rather than solid cancers and has only very recently been reported among patients receiving ICIs. While identification of hemophagocytosis on bone marrow examination is pathognomonic, this feature is not essential for confirming a diagnosis of HLH. Prompt recognition of suspicious laboratory and clinical features by medical oncologists and engagement with other relevant disciplines is hence critical to ensure optimal management of the condition.
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Affiliation(s)
- Sarah Heynemann
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Vinay Vanguru
- Department of Haematology, Royal Prince Alfred, Camperdown, New South Wales, Australia
| | - Stephen Adelstein
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
- Department of Clinical Immunology and Allergy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Steven Kao
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
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10
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Ota H, Munechika M, Tobino K, Uchida K, Muarakami Y. A Case Report of Hemophagocytic Lymphohistiocytosis and Meningitis Due to Atezolizumab Treatment for Lung Adenocarcinoma. Cureus 2024; 16:e58253. [PMID: 38745801 PMCID: PMC11091938 DOI: 10.7759/cureus.58253] [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] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are used to treat a variety of tumors. Despite their broad beneficial effects, these inhibitors can cause immune-related adverse events (irAEs) and even death. Hemophagocytic lymphohistiocytosis (HLH) and meningitis, although infrequent, can be aggressive and life-threatening due to excessive immune activation. Herein, we report a case of an 80-year-old man who developed HLH after receiving atezolizumab monotherapy as a second-line treatment for lung adenocarcinoma. He was treated for HLH with oral prednisolone (PSL), but further ataxia and dysuria developed, and a lumbar puncture diagnosed meningitis. Both HLH and meningitis improved with continued oral PSL treatment. This is the first case of atezolizumab-induced HLH with meningitis and highlights the importance of early diagnosis and treatment for rare irAE.
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Affiliation(s)
- Hiroaki Ota
- Respiratory Medicine, Iizuka Hospital, Iizuka, JPN
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11
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Tong X, Zhan T, Dong X, Xu D. Fever of unknown origin associated with immune checkpoint inhibitors. Front Immunol 2024; 15:1364128. [PMID: 38533499 PMCID: PMC10963505 DOI: 10.3389/fimmu.2024.1364128] [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: 01/01/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
Since the approval for the treatment of melanoma in 2014, immune checkpoint inhibitors (ICIs) have revolutionized the therapy pattern across various malignancies. Coinciding with their frequent usage, their adverse effects, including fever, cannot be neglected. In the context of cancer diseases and cancer treatments, fever of unknown origin (FUO), which has long posed a challenge for clinicians in terms of diagnosis and management, brings forth new connotation and significance. In this paper review, we present the concept of ICIs-associated FUO, consider activated immune system and elevated cytokines as common mechanisms by which ICIs induce fever and various immune-related adverse events (irAEs), summarize and compare the primary etiologies of ICI-associated FUO, and compare it with conventional types of FUO.
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Affiliation(s)
- Xu Tong
- The Second Clinical Medical College, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tao Zhan
- The Second Clinical Medical College, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaoqin Dong
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dong Xu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei, China
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12
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Zhai C, Jin X, You L, Yan N, Dong J, Qiao S, Zhong Y, Zheng Y, Pan H. Hemophagocytic lymphohistiocytosis following pembrolizumab and bevacizumab combination therapy for cervical cancer: a case report and systematic review. BMC Geriatr 2024; 24:32. [PMID: 38191289 PMCID: PMC10773023 DOI: 10.1186/s12877-023-04625-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Programmed cell death protein 1 (PD-1) checkpoint inhibitors such as pembrolizumab are novel therapeutics used to treat various advanced malignancies. Immune-related adverse events are common, among the most serious of these toxicities is hemophagocytic lymphohistiocytosis (HLH), which is a life-threatening disorder of unbridled immune activation but has not been properly established. METHODS We have procured the first case of hemophagocytic lymphohistiocytosis as an aftermath of treatment with pembrolizumab from the Sir Run Run Shaw Hospital, Zhejiang University, China. In a pursuit to enhance the understanding of this condition, a comprehensive systematic review was performed encompassing all reported instances of ICI-associated Hemophagocytic lymphohistiocytosis within the realms of PubMed and Embase databases. RESULTS We detail the recovery of a cervical cancer patient with a history of psoriasis who developed HLH after combined pembrolizumab and bevacizumab treatment. Remarkably, tumor lesions exhibited substantial and sustained regression. From an analysis of 52 identified Immune Checkpoint Inhibitor (ICI)-related HLH cases, we discovered that HLH often occurred within the first two treatment cycles and approximately 20% of these patients had a history of autoimmune-related diseases. Despite a 15% mortality rate, the majority of patients experienced positive outcomes. Notably, in instances of recovery from HLH, 80% showed positive tumor outcomes. Even after discontinuation of ICI treatment, tumor control persisted in some cases. CONCLUSION We identified the first case of HLH caused by ICI treatment in cervical cancer and summarized the possible occurrence factors of these cases, the treatment outcomes of HLH, and the impact on tumor outcomes.
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Affiliation(s)
- Chongya Zhai
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China
| | - Xuanhong Jin
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China
| | - Liangkun You
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China
| | - Na Yan
- Key Laboratory of Digital Technology in Medical Diagnostics of Zhejiang Province, Dian Diagnostics Group Co.,Ltd, Hangzhou, China
| | - Jie Dong
- Department of Medical Oncology, Shaoxing Campus, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Shaoxing, China
| | - Sai Qiao
- Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuhong Zhong
- Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Zheng
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China.
| | - Hongming Pan
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China.
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13
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Rosado FG, Gopal P. Laboratory Features and Pathology of Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:43-58. [PMID: 39117807 DOI: 10.1007/978-3-031-59815-9_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
The laboratory diagnosis of cytokine storm syndromes (CSSs), i.e., hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS), is often challenging. The laboratory features using routinely available tests lack specificity, whereas confirmatory testing is available in only few laboratories in the United States. The disease mechanisms are still largely unclear, particularly in adults. In this chapter, the pathogenesis of CSSs, their associated laboratory findings, and recommended diagnostic strategies are reviewed.
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Affiliation(s)
- Flavia G Rosado
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Purva Gopal
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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14
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Ali SB, Kuss B, Karapetis C, Hughes T, Smith A. Immune checkpoint inhibitor-associated hemophagocytic lymphohistiocytosis in a patient with chronic lymphocytic leukemia. Immunotherapy 2023; 15:1531-1537. [PMID: 37933523 DOI: 10.2217/imt-2023-0140] [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: 11/08/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare complication of immune checkpoint inhibitor therapy. A 55-year-old male with stable chronic lymphocytic leukemia presented with fevers and symptomatic anaemia after nine cycles of nivolumab for metastatic melanoma. Investigations were consistent with autoimmune haemolytic anemia and corticosteroids were initiated. Thrombocytopenia and elevated liver enzymes without evidence of chronic lymphocytic leukaemia transformation was present. Ferritin was elevated, and thus HLH was considered and subsequently confirmed on a bone marrow biopsy. Corticosteroid monotherapy was continued, with resolution of fevers and improvement in cytopenias and liver enzymes. A six month corticosteroid tapering regimen was initiated, and he remains in HLH remission. This case highlights the importance of prompt recognition of immune checkpoint inhibitor-related HLH in patients with concurrent haematological malignancy.
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MESH Headings
- Male
- Humans
- Middle Aged
- Lymphohistiocytosis, Hemophagocytic/diagnosis
- Lymphohistiocytosis, Hemophagocytic/drug therapy
- Lymphohistiocytosis, Hemophagocytic/complications
- Immune Checkpoint Inhibitors/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Nivolumab/adverse effects
- Thrombocytopenia
- Adrenal Cortex Hormones/therapeutic use
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Affiliation(s)
- Syed B Ali
- Department of Clinical Immunology & Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine & Public Health, Flinders University, Bedford Park, 5042, Australia
| | - Bryone Kuss
- Department of Haematology, Flinders Medical Centre, Bedford Park, 5042, Australia
| | - Chris Karapetis
- Department of Oncology, Flinders Medical Centre, Bedford Park, 5042, Australia
| | - Tiffany Hughes
- Department of Clinical Immunology & Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine & Public Health, Flinders University, Bedford Park, 5042, Australia
| | - Anthony Smith
- Department of Clinical Immunology & Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine & Public Health, Flinders University, Bedford Park, 5042, Australia
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15
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Samar MR, Shoaib D, e Zehra N, Moosajee M. Late-onset Familial Hemophagocytic Lymphohistiocytosis in a survivor of Hodgkin's Lymphoma. Leuk Res Rep 2023; 21:100394. [PMID: 38628817 PMCID: PMC11019264 DOI: 10.1016/j.lrr.2023.100394] [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: 08/02/2023] [Accepted: 10/20/2023] [Indexed: 04/19/2024] Open
Abstract
Hemophagocytic Lymphohistiocytosis is an inflammatory condition which results in over activation of the immune system. It could be either sporadic or familial. The familial subtype is linked with various genetic mutations and is commonly a disease of the young. Here we report a case of HLH in an adult, occurring in the background of a successfully treated hematological malignancy. Upon workup, he was also found to have pathogenic STXBP2 mutation, suggesting HLH of familial origin. To date, only few cases of adult-onset familial HLH have been brought to light.
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Affiliation(s)
- Mirza Rameez Samar
- Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Daania Shoaib
- Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Nida e Zehra
- Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Munira Moosajee
- Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan
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16
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Kakehi M, Amano S, Sano C, Ohta R. Atypical Adult Still's Disease Complicated by Hemophagocytic Syndrome in an Older Patient: A Case Report. Cureus 2023; 15:e46922. [PMID: 38021678 PMCID: PMC10640387 DOI: 10.7759/cureus.46922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Hyperferritinemia can occur in various diseases, making the differential diagnoses diverse and often fatal. The macrophage-activated syndrome (MAS) is a differential diagnosis of hyperferritinemia in which systemic macrophages are activated and cause various symptoms. Many cases are complicated by hemophagocytic syndrome, causing pancytopenia, which can be fatal. Furthermore, it is challenging to diagnose hyperferritinemia in elderly patients, and the disease may develop into a fever of unknown origin. We report the case of a 93-year-old man with aspiration pneumonia, followed by intermittent prolonged fever complicated by abnormal hyperferritinemia and leukopenia. Based on his general condition, he was diagnosed with atypical adult Still's disease and treated with steroid pulses and tocilizumab, temporarily relieving his symptoms. However, the patient eventually developed sepsis and could not be saved. Diagnosis of hyperferritinemia in the elderly population is complex and requires immediate attention. However, invasive intervention may lead to the deterioration of an elderly patient's condition. In the context of medical care for the elderly at a community hospital, it is necessary to provide comprehensive care for those in critical condition, considering the degree of invasiveness of examinations and procedures.
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Affiliation(s)
- Minami Kakehi
- Family Medicine, Shimane University Medical School, Izumo, JPN
| | - Shiho Amano
- Community Care, Unnan City Hospital, Unnan, JPN
| | - Chiaki Sano
- Community Medicine, Shimane University Faculty of Medicine, Izumo, JPN
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17
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Ohjino Y, Nishikawa K, Nishikura N, Sano C, Ohta R. A Case of Suspected T-cell Intravascular Lymphoma Mimicking Multiple Hepatic Abscesses and Adult-Onset Still's Disease. Cureus 2023; 15:e47534. [PMID: 38021999 PMCID: PMC10664968 DOI: 10.7759/cureus.47534] [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] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Diagnosing hyperferritinemia can be challenging due to the nonspecific nature of symptoms and various potential causes. This case report discusses the intricacies faced when diagnosing an elderly individual with hyperferritinemia, which eventually led to a specific diagnosis. An elderly patient presented with two months of fatigue, fever, and malaise, initially receiving several diagnoses. Despite some treatments, the patient's condition worsened, prompting further evaluation. Further investigation revealed a rare diagnosis. The progression of the disease led to the decision of palliative care. This case emphasizes the challenges in diagnosing elderly individuals and the importance of comprehensive follow-up and broad differential diagnosis. The need for a thorough investigation in the face of specific indicators is underscored. The patient's non-response to certain treatments required the consideration of less common conditions in the differential diagnosis. The case offers insights into addressing treatment suitability and making necessary adjustments. The situation underscores the need for careful evaluation, especially in unusual presentations, and the importance of timely conversations about care options. Lessons from this case assist healthcare professionals in understanding and managing intricate presentations in the elderly.
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Affiliation(s)
| | | | | | - Chiaki Sano
- Community Medicine Management, Shimane University Faculty of Medicine, Izumo, JPN
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18
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Dirven I, Vander Mijnsbrugge AS, Mignon S, Tijtgat J, Kint N, Neyns B. Auto-immune hemolytic anemia and hemophagocytic lymphohistiocytosis as immune-related adverse event in patients with metastatic melanoma and concurrent chronic lymphocytic leukemia: a case series and literature review. Melanoma Res 2023; 33:338-344. [PMID: 37114670 DOI: 10.1097/cmr.0000000000000895] [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: 04/29/2023]
Abstract
Auto-immune hemolytic anemia (AIHA) and hemophagocytic lymphohistiocytosis (HLH) are both rare immune-related adverse events (irAEs) following treatment with immune checkpoint inhibitors. Consensus treatment guidelines are currently lacking. Patients with a solid malignancy and a concurrent lymphoproliferative disorder, such as chronic lymphocytic leukemia (CLL), might be more prone to develop hematological irAEs. We report the case history of two patients, diagnosed with CLL, who during treatment for metastatic melanoma with nivolumab, a PD-1 immune checkpoint blocking mAb, developed AIHA and HLH in combination with AIHA. Furthermore, we provide a review of the literature on published cases of immune-related AIHA and HLH and their correlation with CLL.
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MESH Headings
- Humans
- Melanoma/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphohistiocytosis, Hemophagocytic/chemically induced
- Lymphohistiocytosis, Hemophagocytic/complications
- Skin Neoplasms
- Anemia, Hemolytic
- Neoplasms, Second Primary
- Anemia, Hemolytic, Autoimmune/chemically induced
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Affiliation(s)
- Iris Dirven
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
| | - An-Sofie Vander Mijnsbrugge
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
| | - Sacha Mignon
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
| | - Jens Tijtgat
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
| | - Nicolas Kint
- Department of Hematology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Bart Neyns
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel)
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19
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Polley DJ, Latham P, Choi MY, Buhler KA, Fritzler MJ, Fritzler ML. Identification of novel clusters of co-expressing cytokines in a diagnostic cytokine multiplex test. Front Immunol 2023; 14:1223817. [PMID: 37600813 PMCID: PMC10432683 DOI: 10.3389/fimmu.2023.1223817] [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: 05/16/2023] [Accepted: 07/10/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Cytokines are mediators of the immune system that are essential for the maintenance, development and resolution of immune responses. Beneficial immune responses depend on complex, interdependent networks of signaling and regulatory events in which individual cytokines influence the production and release of others. Since disruptions in these signaling networks are associated with a wide spectrum of diseases, cytokines have gained considerable interest as diagnostic, prognostic and precision therapy-relevant biomarkers. However, currently individual cytokines testing has limited value because the wider immune response context is often overlooked. The aim of this study was to identify specific cytokine signaling patterns associated with different diseases. Methods Unbiased clustering analyses were performed on a clinical cytokine multiplex test using a cohort of human plasma specimens drawn from individuals with known or suspected diseases for which cytokine profiling was considered clinically indicated by the attending physician. Results and discussion Seven clusters of co-expressing cytokines were identified, representing common patterns of immune activation. Common expression profiles of the cytokine clusters and preliminary associations of these profiles with specific diseases or disease categories were also identified. These findings increase our understanding of the immune environments underlying the clinical presentations of patients of inflammatory, autoimmune and neoplastic diseases, which could then improve diagnoses and the identification of evidence-based treatment targets.
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Affiliation(s)
| | - Penny Latham
- Eve Technologies Corporation, Calgary, AB, Canada
| | - May Y. Choi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Katherine A. Buhler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marvin J. Fritzler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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20
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He Y, Gao Y, Ping L, He H, Huang C, Bai B, Wang X, Li Z, Cai Q, Huang Y, Pan X, Zeng W, Liu Y, Huang H. The emerging role of anti-PD-1 antibody-based regimens in the treatment of extranodal NK/T-cell lymphoma-associated hemophagocytic lymphohistiocytosis. J Cancer Res Clin Oncol 2023; 149:2017-2027. [PMID: 35809114 DOI: 10.1007/s00432-022-04147-2] [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: 04/22/2022] [Accepted: 06/13/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE Anti-PD-1 antibody (anti-PD-1 mAb) showed favorable outcomes in some patients with relapsed/refractory (r/r) extranodal NK/T-cell lymphoma (ENKTL). However, the role of anti-PD-1 antibody in NK/T-cell lymphoma-associated hemophagocytic lymphohistiocytosis (NK/T-LAHS) remains unclear. Here, we evaluated the efficacy and toxicity of anti-PD-1 antibody-based treatment in NK/T-LAHS patients. METHODS The clinical data of 98 patients diagnosed with NK/T-LAHS at Sun Yat-sen University Cancer Center and the First Affiliated Hospital of Guangdong Pharmaceutical University from May 2014 to November 2021 were retrospectively analyzed. All patients received anti-HLH [HLH-2004 (etoposide, dexamethasone, cyclosporine A) or DEP-based (liposomal doxorubicin, etoposide, methylprednisolone)] regimen and sequential anti-ENKTL chemotherapy (ChT) combined with anti-PD-1 antibody or not. RESULTS The overall response rate (ORR) of the anti-PD-1 mAb plus ChT regimens was higher than that of the ChT regimens (73.3% vs. 45.5%, P = 0.041). The toxicity of the anti-PD-1 mAb plus ChT regimens was tolerable. Except for higher rate of neutropenia, no significant difference in adverse events (AEs) was observed between the two groups. When the optimal response to anti-ENKTL was achieved, the median EBV DNA levels in patients who received anti-PD-1 mAb plus ChT were significantly lower than patients who received ChT only (878 copies/mL vs. 18,600 copies/mL, P = 0.001). With a median follow-up of 26.6 months (range 0-65.9 months), the median overall survival (mOS) was 3.5 months (95% CI:2.3-4.7 months). Patients treated with anti-PD-1 mAb plus ChT experienced a longer mOS than those who received ChT only [5.2 months (95% CI: 2.5-7.8 months) vs. 1.5 months (95% CI: 0.5-2.6 months), P = 0.002]. Cox multivariate analysis found that anti-PD-1 mAb was an independent prognostic factor for all NK/T-LAHS patients. CONCLUSION In conclusion, anti-PD-1 mAb combined with ChT regimens seemed to be associated with prolonged survival in NK/T-LAHS patients and may represent a potentially promising treatment strategy for this population.
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Affiliation(s)
- Yanxia He
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yan Gao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Liqin Ping
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Haixia He
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Cheng Huang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Bing Bai
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Xiaoxiao Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Zhiming Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Qingqing Cai
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yuhua Huang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Xueyi Pan
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Wenbin Zeng
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Yanan Liu
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Huiqiang Huang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China.
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China.
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21
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Recurrent hemophagocytic lymphohistiocytosis in advanced melanoma treated with two different BRAF/MEK-inhibitor regimens. Melanoma Res 2023; 33:159-161. [PMID: 36815470 DOI: 10.1097/cmr.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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22
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Lee JC, Logan AC. Diagnosis and Management of Adult Malignancy-Associated Hemophagocytic Lymphohistiocytosis. Cancers (Basel) 2023; 15:1839. [PMID: 36980725 PMCID: PMC10046521 DOI: 10.3390/cancers15061839] [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: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe, dysregulated inflammation driven by the inability of T cells to clear an antigenic target. When associated with malignancy (mHLH), the HLH syndrome is typically associated with extremely poor survival. Here, we review the diagnosis of secondary HLH (sHLH) syndromes in adults, with emphasis on the appropriate workup and treatment of mHLH. At present, the management of HLH in adults, including most forms of mHLH, is based on the use of corticosteroids and etoposide following the HLH-94 regimen. In some cases, this therapeutic approach may be cohesively incorporated into malignancy-directed therapy, while in other cases, the decision about whether to treat HLH prior to initiating other therapies may be more complicated. Recent studies exploring the efficacy of other agents in HLH, in particular ruxolitinib, offer hope for better outcomes in the management of mHLH. Considerations for the management of lymphoma-associated mHLH, as well as other forms of mHLH and immunotherapy treatment-related HLH, are discussed.
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Affiliation(s)
- Jerry C. Lee
- Hematology, Blood and Marrow Transplantation, and Cellular Therapy Program, Division of Hematology/Oncology, University of California, San Francisco, CA 94143, USA;
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23
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Diaz L, Jauzelon B, Dillies AC, Le Souder C, Faillie JL, Maria ATJ, Palassin P. Hemophagocytic Lymphohistiocytosis Associated with Immunological Checkpoint Inhibitors: A Pharmacovigilance Study. J Clin Med 2023; 12:jcm12051985. [PMID: 36902771 PMCID: PMC10004618 DOI: 10.3390/jcm12051985] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/16/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Acquired hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal condition characterized by hyperactivation of macrophages and cytotoxic lymphocytes, combining a series of non-specific clinical symptoms and laboratory disorders. Etiologies are multiple: infectious (mainly viral) but also oncologic, autoimmune or drug-induced. Immune checkpoint inhibitors (ICI) are recent anti-tumor agents associated with a novel profile of adverse events triggered by immune system over-activation. Here, we sought to provide a comprehensive description and analysis of HLH cases reported with ICI since 2014. METHODS Disproportionality analyses were performed in order to further explore the association between ICI therapy and HLH. We selected 190 cases, 177 from the World Health Organization pharmacovigilance database and 13 from the literature. Detailed clinical characteristics were retrieved from the literature and from the French pharmacovigilance database. RESULTS The cases of HLH reported with ICI concerned men in 65% of cases with a median age of 64 years. HLH occurred in an average of 102 days after the initiation of ICI treatment and mostly concerned nivolumab, pembrolizumab and nivolumab/ipilimumab combination. All cases were considered serious. Most cases presented a favorable outcome (58.4%); however, death was reported for 15.3% of patients. Disproportionality analyses showed that HLH was seven times more frequently reported with ICI therapy than with other drugs and three times more than with other antineoplastic agents. CONCLUSIONS Clinicians should be aware of the potential risk of ICI-related HLH to improve the early diagnosis of this rare immune-related adverse event.
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Affiliation(s)
- Laurine Diaz
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
| | - Benjamin Jauzelon
- Internal Medicine & Immuno-Oncology (MedI2O), CHU Montpellier, 34000 Montpellier, France
| | - Anne-Charlotte Dillies
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
| | - Cosette Le Souder
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
| | - Jean-Luc Faillie
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
- Desbrest Institute of Epidemiology and Public Health (IDESP), Montpellier University, INSERM, 34000 Montpellier, France
| | - Alexandre Thibault Jacques Maria
- Internal Medicine & Immuno-Oncology (MedI2O), CHU Montpellier, 34000 Montpellier, France
- Institute for Regenerative Medicine and Biotherapy (IRMB), Montpellier University, 34000 Montpellier, France
| | - Pascale Palassin
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
- Correspondence: ; Tel.: +33-4-67336756; Fax: +33-4-67336751
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24
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Liu LL, Skribek M, Harmenberg U, Gerling M. Systemic inflammatory syndromes as life-threatening side effects of immune checkpoint inhibitors: case report and systematic review of the literature. J Immunother Cancer 2023; 11:jitc-2022-005841. [PMID: 36878533 PMCID: PMC9990684 DOI: 10.1136/jitc-2022-005841] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 03/08/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are associated with a wide range of immune-related adverse events. As oncological indications for ICIs widen, their rare side effects become increasingly visible in clinical practice and impact therapy decisions.Here, we report a rare case of early-onset, mild cytokine release syndrome (CRS) in a patient who received ICIs for a metastasized renal cell carcinoma, which led to treatment discontinuation.We further provide a systematic review of the literature of CRS and related life-threatening side effects of ICI treatment, such as hemophagocytic lymphohistiocytosis (HLH). We searched Medline, Embase and the Web of Science Core Collection from inception to October 2021 for reports on CRS, cytokine storm, macrophage activation syndrome, HLH, and related hyperinflammatory disorders in patients with solid cancers receiving ICIs. We found n=1866 articles, which were assessed for eligibility independently by two examiners. Of those, n=49 articles reporting on n=189 individuals were eligible for review. We found that the median time from last infusion to the occurrence of CRS/HLH was approximately nine days, while the onset of symptoms varied from immediately after infusion to one month after treatment. Most patients were treated with either corticosteroids or the anti-interleukin 6 (IL-6) antibody tocilizumab, and although the majority of patients recovered, a few cases were fatal. Concomitant IL-6 and ICI treatment were reported as beneficial for both the antitumoral effect and for limiting side effects. Data from international pharmacovigilance databases underscored that ICI-related CRS and HLH are rare events, but we identified significant differences in reported frequencies, which might suggest substantial under-reporting.The results from this first systematic review of CRS/HLH due to ICI therapy highlight that life-threatening systemic inflammatory complications of ICIs are rare and might be associated with fatal outcome in approximately 10% of patients. Limited data support the use of IL-6 inhibitors in combination with ICIs to augment the antitumoral effect and reduce hyperinflammation.
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Affiliation(s)
- Lisa L Liu
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden .,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Skribek
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden.,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Harmenberg
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden.,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Gerling
- Theme Cancer, Karolinska University Hospital, Stockholm, Sweden .,Department of Biosciences and Nutrition, Karolinska Institute, Stockholm, Sweden
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PD-1 Checkpoint Blockade in Patients for Acute Myeloid Leukemia after HSCT Relapse Resulted in Severe GVHD and sHLH. Case Rep Hematol 2022; 2022:1705905. [PMID: 36590870 PMCID: PMC9800091 DOI: 10.1155/2022/1705905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 11/08/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Treatment with immune checkpoint inhibitors (ICI) such as carrizumab leads to immune-mediated adverse effects including severe acute graft versus host disease (aGVHD) and secondary hemophagocytic syndrome (sHLH). Herein, we present two cases where aGVHD and sHLH developed after ICI administration, which was treated using methylprednisolone (MP). They developed high-grade fever complicated with liver dysfunction and diarrhea 1 day after ICI administration. Treatment with MP does not alleviate symptoms because of steroid resistance. Hyperbilirubinemia, rash with blisters, and watery diarrhea showed severe aGVHD. Hyperferritinemia, hypertriglyceridemia, and cytopenias suggested the diagnosis of HLH and met the criteria for sHLH diagnosis. They were thus administered intravenous high-dose MP, methotrexate (MTX), basiliximab, ruxolitinib, etc, which resolved these symptoms.
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Desroche T, Chong-Si-Tsaon A, Raffray L. Hemophagocytic lymphohistiocytosis-like presentation of malignant melanoma. Int J Lab Hematol 2022; 44:1005-1006. [PMID: 35699107 DOI: 10.1111/ijlh.13909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/27/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Tannvir Desroche
- Department of Internal Medicine and Dermatology, CHU Réunion, Saint Denis, France
| | | | - Loïc Raffray
- Department of Internal Medicine and Dermatology, CHU Réunion, Saint Denis, France
- Unité Mixte Processus Infectieux en Milieu Insulaire Tropical (PIMIT), Plateforme Technologique CYROI, INSERM U1187, IRD 249, CNRS 9192, Université de La Réunion, Sainte Clotilde, La Réunion, France
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Hemophagocytic Lymphohistiocytosis as a complication of immune checkpoint inhibitor therapy for sarcoma. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2022. [DOI: 10.1016/j.cpccr.2022.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Gould Rothberg BE, Quest TE, Yeung SCJ, Pelosof LC, Gerber DE, Seltzer JA, Bischof JJ, Thomas CR, Akhter N, Mamtani M, Stutman RE, Baugh CW, Anantharaman V, Pettit NR, Klotz AD, Gibbs MA, Kyriacou DN. Oncologic emergencies and urgencies: A comprehensive review. CA Cancer J Clin 2022; 72:570-593. [PMID: 35653456 DOI: 10.3322/caac.21727] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.
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Affiliation(s)
- Bonnie E Gould Rothberg
- Yale Cancer Center Innovations Laboratory, Yale Comprehensive Cancer Center, New Haven, Connecticut
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lorraine C Pelosof
- Office of Oncologic Diseases, US Food and Drug Administration, Silver Spring, Maryland
| | - David E Gerber
- Division of Hematology-Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas
| | - Justin A Seltzer
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mira Mamtani
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robin E Stutman
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Venkataraman Anantharaman
- Department of Emergency Medicine, Singapore General Hospital, SingHealth Duke-National University of Singapore Academic Medical Center, Singapore, Singapore
| | - Nicholas R Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam D Klotz
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Gibbs
- Department of Emergency Medicine, Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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PD-1 Blockader-associated Atypical Hemophagocytic Lymphohistiocytosis: A Cautionary Case Report. Transfus Apher Sci 2022; 62:103603. [PMID: 36470726 DOI: 10.1016/j.transci.2022.103603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/12/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a fatal immune hyperactivity syndrome with high mortality. It seriously endangers human health. HLH associated with immune checkpoint inhibitors is rare, and no particular diagnostic guidelines or treatment regimens exist. A 36-year-old patient with metastatic right atrial angiosarcoma was treated with programmed cell death-1 (PD-1) blockader toripalimab and pazopanib, a vascular endothelial growth factor receptor blockader. However, the patient presented to our center with HLH, and he accepted combination therapy of therapeutic plasma exchange (TPE) and immunotherapy. The patient improved quickly, after only one TPE procedure. Finally, he was discharged after completing two TPE procedures. We summarize a case of PD-1 blocker associated atypical HLH that was successfully treated with TPE. Further evidence is needed to elucidate whether TPE has therapeutic potential for immunotherapy associated HLH.
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Rubio-Perez J, Rodríguez-Perez ÁR, Díaz-Blázquez M, Moreno-García V, Dómine-Gómez M. Treatment-related hemophagocytic lymphohistiocytosis due to atezolizumab: a case report and review of the literature. J Med Case Rep 2022; 16:365. [PMID: 36195892 PMCID: PMC9531226 DOI: 10.1186/s13256-022-03585-3] [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: 08/03/2021] [Accepted: 08/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background Immune checkpoint inhibitors avoid inhibition of T-cell responses, upregulating antitumor immune response. Moreover, a dysregulation with hyperactive immune response can be caused, some of them underdiagnosed. Hemophagocytic lymphohistiocytosis is a rare and often fatal syndrome of uncontrolled and ineffective hyperinflammatory response that triggers an inflammatory cascade that can lead in many cases to death. Case presentation We report the case of a 67-year-old Caucasian man with stage IV lung adenocarcinoma who developed hemophagocytic lymphohistiocytosis after initiation of atezolizumab, an antagonist of programmed death-ligand 1. Even with early diagnosis and proper treatment, death occurs in approximately half of all cases reported. Conclusion Key markers are needed to better identify patients at risk of developing severe immune-related adverse events. In addition to key markers, a higher degree of suspicion and early intervention are needed to improve outcomes in acquired hemophagocytic lymphohistiocytosis, especially with the increasingly and expanding use of immune activation.
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Affiliation(s)
- Jaime Rubio-Perez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.
| | - Ángel Ricardo Rodríguez-Perez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.
| | - María Díaz-Blázquez
- Anatomic Pathology Unit Department, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Victor Moreno-García
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.,START Madrid-FJD, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Manuel Dómine-Gómez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain
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Holmes Z, Courtney A, Hiong A. Haemophagocytic lymphohistiocytosis as a complication of combination anti-PD-1 and anti-CTLA-4 checkpoint inhibitor immunotherapy for metastatic melanoma, and the outcome of rechallenge with single-agent anti-PD-1 immunotherapy. BMJ Case Rep 2022; 15:e251052. [PMID: 35948362 PMCID: PMC9379485 DOI: 10.1136/bcr-2022-251052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 12/11/2022] Open
Abstract
A woman with metastatic melanoma was treated with immunotherapy induction with ipilimumab and nivolumab and radiotherapy to liver metastases. The patient deteriorated shortly thereafter, becoming febrile and hypotensive and requiring admission to the intensie care unit (ICU) for inotrope support. Failure to respond to antibiotics and a negative septic screen prompted further investigation, which ultimately led to a diagnosis of haemophagocytic lymphohistiocytosis (HLH). The patient improved on high dose steroids and was discharged home. Months later, in the context of progressive melanoma, the patient was re-challenged with nivolumab monotherapy and subsequently experienced recurrence of HLH, confirming the aetiology as being immunotherapy related. This case serves as a reminder to consider HLH where there are fevers of unknown origin in an unwell patient receiving immune checkpoint inhibitor therapy and also highlights immunotherapy as a potential cause for HLH, which has rarely been reported in the literature to date.
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Affiliation(s)
- Zachary Holmes
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ashling Courtney
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alison Hiong
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Mechanisms underlying immune-related adverse events during checkpoint immunotherapy. Clin Sci (Lond) 2022; 136:771-785. [PMID: 35621125 DOI: 10.1042/cs20210042] [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: 01/18/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 11/17/2022]
Abstract
Immune checkpoint (IC) proteins are some of the most important factors that tumor cells hijack to escape immune surveillance, and inhibiting ICs to enhance or relieve antitumor immunity has been proven efficient in tumor treatment. Immune checkpoint blockade (ICB) agents such as antibodies blocking programmed death (PD) 1, PD-1 ligand (PD-L) 1, and cytotoxic T lymphocyte-associated antigen (CTLA)-4 have been approved by the U.S. Food and Drug Administration (FDA) to treat several types of cancers. Although ICB agents have shown outstanding clinical success, and their application has continued to expand to additional tumor types in the past decade, immune-related adverse events (irAEs) have been observed in a wide range of patients who receive ICB treatment. Numerous studies have focused on the clinical manifestations and pathology of ICB-related irAEs, but the detailed mechanisms underlying irAEs remain largely unknown. Owing to the wide expression of IC molecules on distinct immune cell subpopulations and the fact that ICB agents generally affect IC-expressing cells, the influences of ICB agents on immune cells in irAEs need to be determined. Here, we discuss the expression and functions of IC proteins on distinct immune cells and the potential mechanism(s) related to ICB-targeted immune cell subsets in irAEs.
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Poornachandra, Wotiye AB, Ayele BA. Hemophagocytic lymphohistiocytosis: An unusual presentation of disseminated tuberculosis: A case report and literature review. J Clin Tuberc Other Mycobact Dis 2022; 27:100313. [PMID: 35372702 PMCID: PMC8971949 DOI: 10.1016/j.jctube.2022.100313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome associated with cytokine storm. Here, we present a patient with acquired HLH associated with Mycobacterial tuberculosis infection. Case presentation We report a 66-year-old hypertensive and diabetic male patient who presented with four days history of fever and abdominal pain. Denied history of cough and weight loss. Laboratory investigation showed: elevated ferritin, C-reactive protein, and triglyceride. Bone marrow examination showed > 50% hemophagocytosis (RBCs and platelets ingested by macrophages), positive acid-fast bacillus for Mycobacterium tuberculosis bacilli, and no evidence of malignancy. Complete blood count showed anemia and thrombocytopenia. The patient fulfilled six out of eight clinical criterions of the acquired Hemophagocytic lymphohistiocytosis (HLH). The patient was managed with anti-tuberculous medications with adjuvant steroid. On the subsequent days, the patient showed significant clinical improvement and discharged home. However, the patient passed away a week after home discharge. Conclusion The present case highlights on the importance of early diagnosis and treatment of acquired HLH associated with tuberculous infection to improve the clinical outcome of the patient.
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Zu C, Wang K, Zhang Q, Hu Y, Huang H. Clinical features of hemophagocytic syndrome following BCMA CAR-T cell therapy in patients with relapsed/refractory multiple myeloma. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:160-166. [PMID: 36161295 PMCID: PMC9353626 DOI: 10.3724/zdxbyxb-2022-0039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/20/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To analyze the clinical features of hemophagocytic syndrome (HLH) following B cell maturation antigen (BCMA) chimeric antigen receptor (CAR) T cell therapy in patients with relapsed/refractory multiple myeloma. METHODS Ninety-nine patients with relapsed/refractory multiple myeloma (including 3 cases of plasma cell leukemia) undergoing BCMA CAR-T cell therapy (monocentric phaseⅠclinical trial, ChiCTR1800017404) in the First Affiliated Hospital, Zhejiang University School of Medicine from July 2018 to December 2021 were enrolled in the study. The baseline features, laboratory findings, treatment, and clinical response of these patients were analyzed. RESULTS CAR-T cell associated HLH (carHLH) occurred in 20 patients (20.20%), and the median onset time was 7(0-19) d after cytokine release syndrome (CRS). Patients with carHLH were maily male patients, and manifested as high percentage of abnormal plasma cells, higher incidence of severe CRS (grade 3-4), and robust expansion of CAR-T cells in the peripheral blood (all P<0.05). The levels of interleukin (IL)-6, IL-10 and interferon (IFN)-γ, the peak value of international normalized ratio and D-dimer were elevated, and the valley value of fibrinogen was decreased in patients with carHLH (all P<0.01). All carHLH patients resolved with proper intervention (including 7 cases with tocilizumab, 5 with steroids, 6 with both). The objective response rate in carHLH patients was slightly higher than that in non-carHLH patients [100.0% (17/17) vs. 94.87% (74/78), P>0.05]. CONCLUSIONS The incidence of carHLH is relatively high in BCMA CAR-T cell treated patients, which is closely related to pretreatment tumor cell percentage in bone marrow, expansion of CAR-T cells and the secretion of cytokines. Medication based on tocilizumab and steroids can achieve considerable therapeutic effects in patient with carHLH.
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Affiliation(s)
- Cheng Zu
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
| | - Kexin Wang
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
| | - Qiqi Zhang
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
| | - Yongxian Hu
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
| | - He Huang
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
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Pacholczak-Madej R, Grela-Wojewoda A, Lompart J, Żuchowska-Vogelgesang B, Ziobro M. Effective Treatment of a Melanoma Patient with Hemophagocytic Lymphohistiocytosis after Nivolumab and Ipilimumab Combined Immunotherapy. Prague Med Rep 2022; 123:35-42. [PMID: 35248163 DOI: 10.14712/23362936.2022.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Immune checkpoint inhibitors have significantly improved the prognosis of melanoma patients. However, these therapies may trigger unexpected immune-related adverse events (irAEs), which are challenging in making the proper diagnosis and providing treatment. Hematological toxicities are possible irAEs, but were poorly evaluated in clinical trials and treatment recommendations of this specific complications are limited. We present a stage IV melanoma patient who developed an extremely rare toxicity - hemophagocytic lymphohistiocytosis (HLH) after the 4th course of combined immunotherapy with nivolumab and ipilimumab. The patient was steroid resistant and only the treatment with various immunosuppressive agents provided control of the disease and finally melanoma regression. In this report, we evaluated the methods of HLH treatment and described our modification of available protocols. Immediate immunosuppression can be life-saving and due to rarity of this condition as well as lack of specific recommendations, every report is valuable for clinicians, especially when treatment was effective.
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Affiliation(s)
- Renata Pacholczak-Madej
- Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland.,Department of Clinical Oncology, The Maria Sklodowska-Curie National Research Institute of Oncology, Cracow, Poland
| | - Aleksandra Grela-Wojewoda
- Department of Clinical Oncology, The Maria Sklodowska-Curie National Research Institute of Oncology, Cracow, Poland
| | - Joanna Lompart
- Department of Clinical Oncology, The Maria Sklodowska-Curie National Research Institute of Oncology, Cracow, Poland
| | - Beata Żuchowska-Vogelgesang
- Department of Clinical Oncology, The Maria Sklodowska-Curie National Research Institute of Oncology, Cracow, Poland
| | - Marek Ziobro
- Department of Clinical Oncology, The Maria Sklodowska-Curie National Research Institute of Oncology, Cracow, Poland.
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Tay SH, Toh MMX, Thian YL, Vellayappan BA, Fairhurst AM, Chan YH, Aminkeng F, Bharwani LD, Huang Y, Mak A, Wong ASC. Cytokine Release Syndrome in Cancer Patients Receiving Immune Checkpoint Inhibitors: A Case Series of 25 Patients and Review of the Literature. Front Immunol 2022; 13:807050. [PMID: 35154124 PMCID: PMC8831742 DOI: 10.3389/fimmu.2022.807050] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/11/2022] [Indexed: 12/23/2022] Open
Abstract
Cytokine release syndrome (CRS) is a phenomenon of immune hyperactivation described in the setting of immunotherapy. Unlike other immune-related adverse events, CRS triggered by immune checkpoint inhibitors (ICIs) is not well described. The clinical characteristics and course of 25 patients with ICI-induced CRS from 2 tertiary hospitals were abstracted retrospectively from the medical records and analyzed. CRS events were confirmed by 2 independent reviewers and graded using the Lee et al. scale. The median duration of CRS was 15.0 days (Q1; Q3 6.3; 29.8) and 10 (40.0%) had multiple episodes of CRS flares. Comparing the clinical factors and biomarkers in Grades 1-2 and 3-5 CRS, we found that patients with Grades 3-5 CRS had following: (i) had longer time to fever onset [25.0 days (Q1; Q3 13.0; 136.5) vs. 3.0 days (Q1; Q3 0.0; 18.0), p=0.027]; (ii) more cardiovascular (p=0.002), neurologic (p=0.001), pulmonary (p=0.044) and rheumatic (p=0.037) involvement; (iii) lower platelet count (p=0.041) and higher urea (p=0.041) at presentation compared to patients with Grades 1-2 CRS. 7 patients (28.0%) with Grades 1-2 CRS were rechallenged using ICIs without event. 9 patients (36.0%) were treated with pulse methylprednisolone and 6 patients (24.0%) were treated with tocilizumab. Despite this, 3 patients (50%) who received tocilizumab had fatal (Grade 5) outcomes from ICI-induced CRS. Longer time to fever onset, lower platelet count and higher urea at presentation were associated with Grade 3-5 CRS. These parameters may be used to predict which patients are likely to develop severe CRS.
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Affiliation(s)
- Sen Hee Tay
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Michelle Min Xuan Toh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yee Liang Thian
- Division of Body Imaging, Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Balamurugan A. Vellayappan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Anna-Marie Fairhurst
- Singapore Immunology Network, Agency for Science, Technology and Research, Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Folefac Aminkeng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lavina D. Bharwani
- Department of Medical Oncology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yiqing Huang
- Department of Haematology-Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Anselm Mak
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Alvin Seng Cheong Wong
- Department of Haematology-Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
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Wilson NR, Lockhart JR, Garcia-Perdomo HA, Oo TH, Rojas-Hernandez CM. Management and Outcomes of Hematological Immune-related Adverse Events: Systematic Review and Meta-analysis. J Immunother 2022; 45:13-24. [PMID: 34469413 DOI: 10.1097/cji.0000000000000390] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
Data regarding clinical outcomes and management of hematological manifestations of immune checkpoint inhibition (ICI) is limited to case reports, series, and a few retrospective reviews. We aimed to determine the rate of response of hematological immune-related adverse events (irAEs) to immunosuppressive therapy. MEDLINE (OVID), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to the present day. Retrospective reports were included without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. The primary outcome of this study was the rate of response to immunosuppression. Eighty studies (14 case series and 66 individual case reports) were analyzed with a total of 135 patients with ICI-related hematological irAEs. Data analysis showed an average proportional response rate to immunosuppression among hematological irAE entities of 50% (range: 25%-70%). The heterogeneity index (I2) was 0% among reports within each entity. There is a wide spectrum of hematological manifestations to ICI therapy, and to date there is no large randomized-controlled trial data to evaluate the efficacy of treatment strategies for hematological irAEs. We found a variable overall response rate to immunosuppression therapy of around 50%, without statistically significant heterogeneity among different irAE types but significant differences among the different countries of publication. Future studies evaluating the optimal dose and duration of immunosuppressive agents for patients with hematological irAEs should be undertaken.
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Affiliation(s)
- Nathaniel R Wilson
- Department of Internal Medicine, The University of Texas McGovern Medical School
| | | | | | - Thein H Oo
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Kobe H, Sato Y, Ohmura K, Fujita S, Mochizuki R, Tomii K. Multitarget therapy for pembrolizumab-induced refractory hemophagocytic lympho histiocytosis. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2021. [DOI: 10.1016/j.cpccr.2021.100120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Masood A, Wahab A, Clifford T, Weaver EJ, Ehsan H, El Ayass W. Secondary hemophagocytic lymphohistiocytosis due to nivolumab/ipilimumab in a renal cell cancer patient-A case report. Clin Case Rep 2021; 9:e05184. [PMID: 34917381 PMCID: PMC8645178 DOI: 10.1002/ccr3.5184] [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] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 12/24/2022] Open
Abstract
Secondary immune-related hemophagocytic lymphohistiocytosis is a rare but life-threatening complication of immune checkpoint inhibitors. HLH-2004 and HLH-1994 guidelines originally developed for primary HLH are the only available guidelines. It has proven to have a good prognosis if diagnosed promptly with discontinuation of immunotherapy and treated with corticosteroid monotherapy.
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Affiliation(s)
- Adeel Masood
- Masters of Public Health in Epidemiology at the University of Alabama at BirminghamAlabamaUSA
- Tidal Health Peninsula RegionalSalisburyMarylandUSA
| | - Ahsan Wahab
- Baptist Medical Center SouthUniversity of Alabama at BirminghamMontgomeryAlabamaUSA
| | | | | | - Hamid Ehsan
- Levine Cancer Institute/Atrium HealthCharlotteNorth CarolinaUSA
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Doyle JJ, Hall JA, Reely K, Dodlapati J. Hemophagocytic lymphohistiocytosis due to pembrolizumab therapy for adenocarcinoma of the lung. Proc AMIA Symp 2021; 34:729-730. [PMID: 34733004 DOI: 10.1080/08998280.2021.1945353] [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: 10/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder of dysregulated inflammation. It is most commonly seen in children who have a predisposing genetic mutation. However, adults can contract an acquired version of the disorder secondary to an infectious, neoplastic, or other inflammatory insult. There have been several documented cases of HLH being induced by treatment with immunotherapy. Here, we present the case of a 71-year-old man who was receiving pembrolizumab for lung adenocarcinoma when he developed HLH following his 14th cycle of therapy. Although bone marrow biopsy was negative, he nevertheless fulfilled the diagnostic criteria of the HLH 2004 report and was treated with high-dose steroids followed by a prolonged taper, with resolution of his symptoms and normalization of his blood counts.
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Affiliation(s)
- James J Doyle
- Department of Internal Medicine, Baylor Scott and White Medical Center - Temple, Temple, Texas
| | - James A Hall
- Department of Hematology-Oncology, Baylor Scott and White Medical Center - Temple, Temple, Texas
| | - Kelsey Reely
- Department of Internal Medicine, Baylor Scott and White Medical Center - Temple, Temple, Texas
| | - Jyothi Dodlapati
- Department of Hematology-Oncology, Central Texas Veterans Healthcare System, Temple, Texas
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Tiu C, Shinde R, Pal A, Biondo A, Lee A, Tunariu N, Jhanji S, Grover V, Tatham K, Gruber P, Banerji U, De Bono JS, Nicholson E, Minchom AR, Lopez JS. A Wolf in Sheep's Clothing: Systemic Immune Activation Post Immunotherapy. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2021; 4:189-195. [PMID: 35665022 PMCID: PMC9138480 DOI: 10.36401/jipo-21-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/25/2022]
Abstract
Introduction Immune checkpoint inhibitors (ICIs) are increasingly a standard of care for many cancers; these agents can result in immune-related adverse events (irAEs) including fever, which is common but can rarely be associated with systemic immune activation (SIA or acquired HLH). Methods All consecutive patients receiving ICIs in the Drug Development Unit of the Royal Marsden Hospital between May 2014 and November 2019 were retrospectively reviewed. Patients with fever ≥ 38°C or chills/rigors (without fever) ≤ 6 weeks of commencing ICIs were identified for clinical data collection. Results Three patients met diagnostic criteria for SIA/HLH with median time to onset of symptoms of 10 days. We describe the clinical evolution, treatment used, and outcomes for these patients. High-dose steroids are used first-line with other treatments, such as tocilizumab, immunoglobulin and therapeutic plasmapheresis can be considered for steroid-refractory SIA/HLH. Conclusion SIA/HLH post ICI is a rare but a potentially fatal irAE that presents with fever and a constellation of nonspecific symptoms. Early recognition and timely treatment are key to improving outcomes.
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Affiliation(s)
- Crescens Tiu
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Rajiv Shinde
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Abhijit Pal
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Andrea Biondo
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Alex Lee
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Nina Tunariu
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Shaman Jhanji
- Critical Care Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Vimal Grover
- Critical Care Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Kate Tatham
- Critical Care Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Pascale Gruber
- Critical Care Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Udai Banerji
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Johann S. De Bono
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Emma Nicholson
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Anna R. Minchom
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
| | - Juanita S. Lopez
- Drug Development Unit, The Royal Marsden Hospital and The Institute of Cancer Research, Sutton, United Kingdom
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Sütcüoğlu O, İlhan A, Tacar SY, Güven DC, Uçar G, Karadurmuş N, Yıldız F, Eraslan E, Uncu D, Tural D, Üner A, Günel N, Özdemir N, Kılıçkap S, Öksüzoğlu ÖB, Özet A, Yazıcı O. Thirty-day mortality rates after immunotherapy initiation. Immunotherapy 2021; 13:1419-1426. [PMID: 34676791 DOI: 10.2217/imt-2021-0082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background: The aim of this study was to determine the cause of death in patients who died within 30 days after the first dose of immunotherapy. Methods: The data of 1432 patients treated with immunotherapy in six tertiary referral hospitals were retrospectively analyzed. Results: It was determined that 34 (2%) of the patients died within 30 days after the first dose of immunotherapy. Death occurred in all patients who received palliative therapy, and most patients (88%) received immunotherapy as second- or subsequent-line of therapy. The most common cause of death was disease progression and thromboembolic events. Conclusion: Preliminary results of the current study might give some clues to define the patient population in whom the fatal side effects of immunotherapy might be encountered.
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Affiliation(s)
- Osman Sütcüoğlu
- Gazi University, Department of Medical Oncology, Ankara, Turkey
| | - Ayşegül İlhan
- Dr. Abdurrahman Yurtaslan Ankara Oncology Training & Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Seher Yıldız Tacar
- Dr. Sadi Konuk Training & Research Hospital, Department of Medical Oncology, Istanbul, Turkey
| | - Deniz Can Güven
- Hacettepe University Cancer Institute, Department of Medical Oncology, Ankara, Turkey
| | - Gökhan Uçar
- Health of Science Ankara City Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Nuri Karadurmuş
- Health Sciences University Gulhane Training & Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Fatih Yıldız
- Dr. Abdurrahman Yurtaslan Ankara Oncology Training & Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Emrah Eraslan
- Dr. Abdurrahman Yurtaslan Ankara Oncology Training & Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Doğan Uncu
- Health of Science Ankara City Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Deniz Tural
- Dr. Sadi Konuk Training & Research Hospital, Department of Medical Oncology, Istanbul, Turkey
| | - Aytuğ Üner
- Gazi University, Department of Medical Oncology, Ankara, Turkey
| | - Nazan Günel
- Gazi University, Department of Medical Oncology, Ankara, Turkey
| | - Nuriye Özdemir
- Gazi University, Department of Medical Oncology, Ankara, Turkey
| | - Saadettin Kılıçkap
- Hacettepe University Cancer Institute, Department of Medical Oncology, Ankara, Turkey
| | - Ömür Berna Öksüzoğlu
- Dr. Abdurrahman Yurtaslan Ankara Oncology Training & Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Ahmet Özet
- Gazi University, Department of Medical Oncology, Ankara, Turkey
| | - Ozan Yazıcı
- Gazi University, Department of Medical Oncology, Ankara, Turkey
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Meazza Prina M, Martini F, Bracchi F, Di Mauro D, Fargnoli A, Motta M, Giussani C, Gobbin G, Taverna M, D'Alessio A. Hemophagocytic syndrome secondary to SARS-Cov-2 infection: a case report. BMC Infect Dis 2021; 21:811. [PMID: 34388982 PMCID: PMC8361241 DOI: 10.1186/s12879-021-06532-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hemophagocytic syndrome (HPS) is a severe hyperinflammatory disease, whose diagnosis is based on the HLH-2004 criteria. In secondary forms of HLH (sHLH), the primary goal is treating the triggering factors such as COVID-19 (Coronavirus disease 2019). The link between the cytokine storm related to COVID-19 and development of sHLH has already been reported since the onset of pandemic, but little is known about clinical manifestations of HLH which develop after the patient’s recovery from mild symptomatic or asymptomatic Sars-CoV-2 infection. Case presentation We describe the case of a woman diagnosed with sHLH related to previous Sars-CoV-2 infection and successfully treated with steroids, colchicine, etoposide and ruxolitinib. Conclusions Our report suggests that HLH-like syndrome might be secondary to Sars-CoV-2 infection, even if the patient utterly recovered from the mildly symptomatic viral infection. In addition, we underline the treatment with low dose ruxolitinib plus etoposide as a potential choice for Sars-CoV-2 infection related HLH.
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Affiliation(s)
- Marco Meazza Prina
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Francesca Martini
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy.
| | - Federico Bracchi
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Daniela Di Mauro
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Anna Fargnoli
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Marco Motta
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Cristina Giussani
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Giovanni Gobbin
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Monica Taverna
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Andrea D'Alessio
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
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Sackstein P, Zaemes J, Kim C. Pembrolizumab-induced cytokine release syndrome in a patient with metastatic lung adenocarcinoma: a case report. J Immunother Cancer 2021; 9:jitc-2021-002855. [PMID: 34330765 PMCID: PMC8327834 DOI: 10.1136/jitc-2021-002855] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 01/22/2023] Open
Abstract
Cytokine release syndrome (CRS) is a well-described immune-related adverse event following chimeric antigen receptor T-cell therapy, but has rarely been reported following anti-programmed death ligand-1 therapy. We report the case of a 55-year-old man with metastatic lung adenocarcinoma who presented with fever, chills and hypotension. Initial labs were notable for highly elevated serum ferritin levels and mildly elevated triglyceride levels. He was ultimately diagnosed with pembrolizumab-induced CRS complicated by multiorgan failure. The patient was treated with steroids and tocilizumab with normalization of inflammatory markers and resolution of renal failure. This case not only highlights the importance of considering CRS in patients who have developed multiorgan failure after immune checkpoint inhibitor therapy, but also demonstrates clinical similarities between CRS and other hyperinflammatory states such as hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Paul Sackstein
- Internal Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Jacob Zaemes
- Internal Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Chul Kim
- Division of Hematology and Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
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Hemophagocytic lymphohistiocytosis in advanced melanoma treated with dabrafenib and trametinib combination: two cases. Melanoma Res 2021; 30:519-523. [PMID: 32784332 DOI: 10.1097/cmr.0000000000000690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has been only rarely reported in patients with BRAF-mutated advanced melanoma treated with targeted therapies and never with first-line dabrafenib/trametinib combination thus far. Two patients treated with first-line dabrafenib and trametinib combination therapy for metastatic melanoma presented with sudden occurrence of fever, cytopenia, rhabdomyolysis, hepatic cytolysis, hypertriglyceridemia and very high ferritin levels after few weeks of treatment, associated with concomitant epstein-barr virus (EBV) reactivation in one patient. In both cases, drug-induced HLH was primarily considered owing to a high H-score and the absence of other etiology. Patients rapidly improved after treatment discontinuation associated with oral steroids in one patient and did not relapse after subsequent treatment resumption with a concurrent anti-BRAF/anti-MEK combination. In metastatic melanoma HLH may occur either spontaneously in the absence of any treatment as a paraneoplastic condition, related to an intercurrent infection or drug-induced mainly with various immunotherapy or with dabrafenib and trametinib following immunotherapy. However, such observations are scarce and these are the first cases of HLH occurring during first-line treatment with dabrafenib and trametinib in advanced melanoma to our knowledge. Pathomechanisms remain to be elucidated since triggering factors may encompass the treatment itself but also other significant actors including viral reactivation along with the underlying disease. The liability of treatment should be considered in cases of HLH occurring in patients with advanced melanoma successfully treated with a combined targeted therapy. A rechallenge with a concurrent anti-BRAF/anti-MEK can be proposed in this setting.
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Switzer B, Haanen J, Lorigan PC, Puzanov I, Turajlic S. Clinical and immunologic implications of COVID-19 in patients with melanoma and renal cell carcinoma receiving immune checkpoint inhibitors. J Immunother Cancer 2021; 9:e002835. [PMID: 34272309 PMCID: PMC8288220 DOI: 10.1136/jitc-2021-002835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/13/2022] Open
Abstract
The clinical and immunologic implications of the SARS-CoV-2 pandemic for patients with cancer receiving systemic anticancer therapy have introduced a multitude of clinical challenges and academic controversies. This review summarizes the current evidence, discussion points, and recommendations regarding the use of immune checkpoint inhibitors (ICIs) in patients with cancer during the SARS-CoV-2 pandemic, with a focus on patients with melanoma and renal cell carcinoma (RCC). More specifically, we summarize the theoretical concepts and available objective data regarding the relationships between ICIs and the antiviral immune response, along with recommended clinical approaches to the management of melanoma and RCC patient cohorts receiving ICIs throughout the course of the COVID-19 pandemic. Additional insights regarding the use of ICIs in the setting of current and upcoming COVID-19 vaccines and broader implications toward future pandemics are also discussed.
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Affiliation(s)
- Benjamin Switzer
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - John Haanen
- Division of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paul C Lorigan
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Division of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Samra Turajlic
- Renal and Skin Units, Royal Marsden NHS Foundation Trust, London, UK
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
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Lymphohistiocytose hémophagocytaire associée aux inhibiteurs du point de contrôle immunologique : étude de pharmacovigilance. Rev Med Interne 2021. [DOI: 10.1016/j.revmed.2021.03.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ghous G, Shoukat HMH, Tarar ZI, Zafar MU, McGreevy JW. Encephalitis Associated With Hemophagocytic Lymphohistiocytosis Secondary to Immune Checkpoint Inhibitors: An Unfamiliar Spin-Off. Cureus 2021; 13:e16079. [PMID: 34345559 PMCID: PMC8324828 DOI: 10.7759/cureus.16079] [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] [Accepted: 06/30/2021] [Indexed: 11/09/2022] Open
Abstract
Checkpoint inhibitors (CPI) have become mainstream in standard therapy in various tumors, especially in malignant melanoma. Despite their widespread beneficial effects, these inhibitors are also notorious for immune-related adverse events (irAEs). Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation. We report a case of a 33-year-old male having a history of metastatic melanoma on immunotherapy (status post two cycles of ipilimumab/nivolumab) admitted for persistent fever and elevated liver enzymes. Additional work showed anemia, thrombocytopenia, hypertriglyceridemia, and hyperferritinemia which meet the diagnostic criteria of histiocyte society HLH-2004. The patient was effectively treated with oral prednisone. Moreover, further complications encompassed slurred speech, word-finding difficulties, ataxia, and lower extremity hyperreflexia concerning for autoimmune encephalitis. He was treated with high-dose IV methylprednisolone (1 gram/day for 3 days) with improvement in symptoms. Autoimmune encephalitis associated with HLH can be fatal - high-dose IV methylprednisolone should be considered, but this avenue still needs to be explored.
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Affiliation(s)
- Ghulam Ghous
- Internal Medicine, University of Missouri Columbia, Columbia, USA
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Krasovitsky M, Borbasi J. Immunotherapy associated pain crisis and the haemophagocytic lymphohistiocytosis syndrome in advanced melanoma: Case report and review of the literature. Palliat Med 2021; 35:972-976. [PMID: 33761792 DOI: 10.1177/02692163211001295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Immunotherapy is increasingly used in the management of early and advanced malignancy. There is limited data regarding the associations between immunotherapy, malignancy, pain and haemophagocytic lymphohistiocytosis. CASE A 40-year-old woman was diagnosed with advanced melanoma, with metastases to her brain, liver, lung, adrenal glands and bone. She had moderate opioid requirements prior to the initiation of therapy. Following doublet immunotherapy with nivolumab and ipilimumab, she experienced a severe pain crisis associated with pyrexia and haemophagocytic lymphohistiocytosis. POSSIBLE COURSES OF ACTION Management dilemmas included whether or not to initiate non-steroidal and steroidal anti-inflammatory therapies, how to address the patient's nociceptive, neuropathic and inflammatory pain, and how to manage the haemophagocytic lymphohistiocytosis. FORMULATION OF MANAGEMENT PLAN The patient required rapid up-titration of analgesia, including methadone, ketamine, hydromorphone, pregabalin and benzodiazepines. Ketorolac and high dose steroid therapy were administered for pain management and to mitigate treatment associated inflammation and haemophagocytic lymphohistiocytosis. OUTCOME The patient's pain was inadequately managed despite multimodal analgesia, and stigmata of inflammation progressed. She died 14 days following treatment. LESSONS The case demonstrates that severe pain may be a consequence of immunotherapy given for advanced, high volume melanoma. RESEARCH AVENUES There is laboratory evidence suggesting an association between immunotherapy, malignancy, pain and haemophagocytic lymphohistiocytosis. Further clinical evidence is required in order to understand these intersecting phenomena.
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Affiliation(s)
- Michael Krasovitsky
- Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia.,Cancer Care Centre, St. George Hospital, Kogarah, NSW, Australia.,Faculty of Medicine, Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia
| | - Jessica Borbasi
- Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia
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Rogers BB, Zawislak C, Wong V. Management of Hematologic Adverse Events Associated With Immune Checkpoint Inhibitors. J Adv Pract Oncol 2021; 12:392-404. [PMID: 34123476 PMCID: PMC8163252 DOI: 10.6004/jadpro.2021.12.4.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Immune checkpoint inhibitors target suppressor receptors, including cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed cell death ligand 1 (PD-L1). The activated T cells are not antigen specific; therefore, the blockade of the immune checkpoint may result in the development of autoimmune adverse events. The most common immune-related adverse events (irAEs) are rash, colitis, and endocrinopathies. However, irAEs that affect the hematologic system are rare and can affect red blood cells (e.g., autoimmune hemolytic anemia), white blood cells, and platelets (e.g., immune thrombocytopenia). Usually one cell line is affected; however, in some cases, multiple cell lines can be affected. Other changes in the hematologic system can also be affected (e.g., cryoglobulinemia, cytokine release syndrome). Due to the rarity and lack of recognition of these AEs, the timing, spectrum of events, and clinical presentation are poorly understood. Management of hematologic irAEs usually involves the use of steroids; however, other agents (e.g., IVIG, cyclosporine, rituximab) or procedures (e.g., plasma exchange, transfusions) can also be used.
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