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Fernández Madrigal L, García Samblás V, Sánchez Escudero L. Experience with pembrolizumab in a renal transplant patient with advanced lung cancer: a case report and review. Anticancer Drugs 2024; 35:563-568. [PMID: 38453157 DOI: 10.1097/cad.0000000000001596] [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: 03/09/2024]
Abstract
The treatment of non-small cell lung cancer (NSCLC) has undergone a change because of the advancement of new therapies, like immune checkpoint inhibitors (ICIs), including pembrolizumab. A 64-year-old woman received a kidney transplant in 2012 because of chronic kidney disease secondary to glomerulosclerosis, diagnosed in 2020 with stage IV NSCLC because of metastasis in the contralateral lung, with programmed death ligand 1programmed death ligand 1 expression of 98%, starting treatment with ICIs, despite presenting a graft rejection risk around 40%. After three ICIs cycles, the patient presented a partial response, with good tolerance to treatment and no signs of graft failure. ICIs were maintained for 19 cycles, until disease progression was observed on a reassessment computed tomography, with a progression-free interval of 18 months, with no evidence of treatment rejection. In transplant patients diagnosed with some type of tumor, antineoplastic therapies may be less effective than in the general population. The current evidence derives from observational studies and case series, since this patient population was excluded from clinical trials, suggesting that the use of ICIs in patients with kidney transplants can lead to acute graft rejection. This is still a controversial issue, it is necessary to improve the quality of the data, with the implementation of clinical trials or prospective studies.
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Affiliation(s)
- Laura Fernández Madrigal
- Medical oncology service, Hospital Juan Ramón Jiménez, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
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Fernández Madrigal L, García Samblásand V, Sánchez Escudero L. Experience with pembrolizumab in a renal transplant patient with advanced lung cancer: a case report and review. Anticancer Drugs 2024; 35:377-382. [PMID: 38271682 DOI: 10.1097/cad.0000000000001570] [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: 01/27/2024]
Abstract
The treatment of non-small cell lung cancer (NSCLC) has undergone a change due to the advancement of new therapies, like immune checkpoint inhibitors (ICIs), including pembrolizumab. A 64-year-old woman received a kidney transplant in 2012 due to chronic kidney disease secondary to glomerulosclerosis, diagnosed in 2020 with stage IV NSCLC due to metastasis in the contralateral lung, with PD-L1 expression of 98%, starting treatment with ICIs, despite presenting a graft rejection risk around 40%. After 3 ICI cycles, the patient presented a partial response, with good tolerance to treatment and no signs of graft failure. ICIs were maintained for 19 cycles, until disease progression was observed on a reassessment computed tomography, with a progression-free interval of 18 months, with no evidence of treatment rejection. In transplant patients diagnosed with some type of tumor, antineoplastic therapies may be less effective than in the general population. The current evidence derives from observational studies and case series, since this patient population was excluded from clinical trials, suggesting that the use of ICIs in patients with kidney transplants can lead to acute graft rejection. This is still a controversial issue, it is necessary to improve the quality of the data, with the implementation of clinical trials or prospective studies.
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Salazar González F, Quiñones Palacios CA, Manzaneque Gordón A, Mazarico Gallego JM, Díaz A, Molas Ferrer G. Delayed immune-related hepatitis after 24 months of pembrolizumab treatment: a case report and literature review. Anticancer Drugs 2024; 35:284-287. [PMID: 37948346 DOI: 10.1097/cad.0000000000001555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Immune checkpoint inhibitors targeting the programmed cell death protein 1 (PD-1) pathway have revolutionized cancer immunotherapy by enhancing the immune system's ability to combat cancer cells. However, this innovative approach comes with a distinctive set of challenges, as these therapies can lead to immune-related adverse events (irAEs) due to their mechanism of action. The most common irAEs involve the skin, gastrointestinal tract, liver, endocrine system, and lungs. These events can range from mild skin rashes to severe colitis, pneumonitis, or even autoimmune organ damage. These adverse effects usually appear with an average of 5-15 weeks from the start of treatment depending on the affected organ. This article presents a case report of a delayed related-mediated hepatitis, after 24 months of treatment with pembrolizumab and almost 3 months after its termination, and a review of the scientific literature on cases of delayed immune-related hepatitis caused by anti-PD1. This case highlights the importance of monitoring patients treated with immune checkpoint inhibitors after cessation as a growing number of patients stop treatment due to achieving durable responses.
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Affiliation(s)
| | | | | | | | - Alba Díaz
- Pathology Department, Hospital Clínic de Barcelona, IDIBAPS and Universitat de Barcelona, CIBEREHD, ISCIII, Barcelona, Spain
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Esposito P, Bottini A, Lecini E, Cappadona F, Piaggio M, Macciò L, Genova C, Viazzi F. Biopsy-proven acute tubulointerstitial nephritis in patients treated with immune checkpoint inhibitors: a pooled analysis of case reports. Front Oncol 2023; 13:1221135. [PMID: 37936605 PMCID: PMC10627243 DOI: 10.3389/fonc.2023.1221135] [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] [Received: 05/11/2023] [Accepted: 10/12/2023] [Indexed: 11/09/2023] Open
Abstract
Introduction Acute kidney injury (AKI) in cancer patients receiving immune checkpoint inhibitors (ICIs) may recognize multiple causes. Here, we reviewed cases of biopsy-proven acute tubulointerstitial nephritis (ATIN) to describe the clinical characteristics and outcomes of this condition. Method We conducted a pooled analysis of clinical cases of ICI-related biopsy-proven ATIN up to 1 May 2022. We collected data on clinical characteristics, AKI, biopsy findings, laboratory examinations, and renal outcomes. Results Eighty-five patients (61.4 ± 19 years, 56 male) were evaluated. Melanoma was the most prevalent diagnosis (51%), followed by non-small cell lung cancer (30%). ICI treatment consisted of PD-1, PDL-1 (nivolumab, pembrolizumab, atezolizumab), and CTLA-4 inhibitors (i) (ipilimumab) or combination PD-1i+CTLA4i. Renal toxicity developed after a median of four cycles of therapy. Fifty-one patients (65.5%) developed the most severe form of AKI- stage 3, including five patients requiring dialysis. All the 19 patients treated with dual ICI blockade developed AKI-stage 3, compared with 29 patients out of the 60 receiving a single agent (p<0.001). Most events were managed with corticosteroids associated with ICI withdrawal. In 15 patients ICI was restarted, but in six (40%) AKI recurred. Overall, 32 patients (40%) presented a complete renal recovery, which chance was inversely associated with dual ICI blockade (OR 0.15, 95CI 0.03-0.7, p=0.01). Conclusion ICI-related ATIN may develop late after the therapy initiation, presenting as severe AKI, particularly in patients with dual ICI blockade. Although this complication may be partially reversible, concerns remain about the renal function sequelae and the possibility of restarting ICI treatment.
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Affiliation(s)
- Pasquale Esposito
- Nephrology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Annarita Bottini
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Elvina Lecini
- Department of Internal Medicine, University of Genova, Genova, Italy
| | | | - Michela Piaggio
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Lucia Macciò
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Carlo Genova
- Department of Internal Medicine, University of Genova, Genova, Italy
- UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Viazzi
- Nephrology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
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Zheng C, Shi Y, Zou Y. T cell co-stimulatory and co-inhibitory pathways in atopic dermatitis. Front Immunol 2023; 14:1081999. [PMID: 36993982 PMCID: PMC10040887 DOI: 10.3389/fimmu.2023.1081999] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/28/2023] [Indexed: 03/14/2023] Open
Abstract
The use of immune checkpoint inhibitors (ICIs) targeting the T cell inhibitory pathways has revolutionized cancer treatment. However, ICIs might induce progressive atopic dermatitis (AD) by affecting T cell reactivation. The critical role of T cells in AD pathogenesis is widely known. T cell co-signaling pathways regulate T cell activation, where co-signaling molecules are essential for determining the magnitude of the T cell response to antigens. Given the increasing use of ICIs in cancer treatment, a timely overview of the role of T cell co-signaling molecules in AD is required. In this review, we emphasize the importance of these molecules involved in AD pathogenesis. We also discuss the potential of targeting T cell co-signaling pathways to treat AD and present the unresolved issues and existing limitations. A better understanding of the T cell co-signaling pathways would aid investigation of the mechanism, prognosis evaluation, and treatment of AD.
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Affiliation(s)
- Chunjiao Zheng
- Skin and Cosmetic Research Department, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuling Shi
- Institute of Psoriasis, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Yuling Shi, ; Ying Zou,
| | - Ying Zou
- Skin and Cosmetic Research Department, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Yuling Shi, ; Ying Zou,
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Naidoo J, Murphy C, Atkins MB, Brahmer JR, Champiat S, Feltquate D, Krug LM, Moslehi J, Pietanza MC, Riemer J, Robert C, Sharon E, Suarez-Almazor ME, Suresh K, Turner M, Weber J, Cappelli LC. Society for Immunotherapy of Cancer (SITC) consensus definitions for immune checkpoint inhibitor-associated immune-related adverse events (irAEs) terminology. J Immunother Cancer 2023; 11:jitc-2022-006398. [PMID: 37001909 PMCID: PMC10069596 DOI: 10.1136/jitc-2022-006398] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/03/2023] Open
Abstract
Immune-related adverse events (irAEs) associated with immune checkpoint inhibitor (ICI) therapy may vary substantially in their clinical presentation, including natural history, outcomes to treatment, and patterns. The application of clinical guidelines for irAE management can be challenging for practitioners due to a lack of common or consistently applied terminology. Furthermore, given the growing body of clinical experience and published data on irAEs, there is a greater appreciation for the heterogeneous natural histories, responses to treatment, and patterns of these toxicities, which is not currently reflected in irAE guidelines. Furthermore, there are no prospective trial data to inform the management of the distinct presentations of irAEs. Recognizing a need for uniform terminology for the natural history, response to treatment, and patterns of irAEs, the Society for Immunotherapy of Cancer (SITC) convened a consensus panel composed of leading international experts from academic medicine, industry, and regulatory agencies. Using a modified Delphi consensus process, the expert panel developed clinical definitions for irAE terminology used in the literature, encompassing terms related to irAE natural history (ie, re-emergent, chronic active, chronic inactive, delayed/late onset), response to treatment (ie, steroid unresponsive, steroid dependent), and patterns (ie, multisystem irAEs). SITC developed these definitions to support the adoption of a standardized vocabulary for irAEs, which will have implications for the uniform application of irAE clinical practice guidelines and to enable future irAE clinical trials.
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Affiliation(s)
- Jarushka Naidoo
- Oncology, Beaumont RCSI Cancer Centre, Dublin, Ireland
- RCSI university of Health Sciences, Beaumont RSCI Cancer Centre, Dublin, Ireland
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Catherine Murphy
- Department of Oncology, St Vincents University Hospital, Dublin, Ireland
- Department of Oncology, Beaumont Hospital, Beaumont RCSI Cancer Centre, Dublin, Ireland
| | - Michael B Atkins
- Oncology, Georgetown University, Washington, District of Columbia, USA
| | - Julie R Brahmer
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | | | | | | | | | | | - Joanne Riemer
- Oncology, Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Caroline Robert
- Institut Gustave-Roussy, Villejuif, France
- Paris-Saclay University, Gif-sur-Yvette, France
| | - Elad Sharon
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Karthik Suresh
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Michelle Turner
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Jeffrey Weber
- Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Laura C Cappelli
- Division of Rheumatology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Immune Checkpoint Inhibitor Associated Autoimmune Encephalitis, Rare and Novel Topic of Neuroimmunology: A Case Report and Review of the Literature. Brain Sci 2022; 12:brainsci12060773. [PMID: 35741658 PMCID: PMC9221042 DOI: 10.3390/brainsci12060773] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/04/2022] [Accepted: 06/09/2022] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are being used in patients with various advanced malignancies, and patient outcomes have improved considerably. Although ICIs can effectively treat tumors, 30-60% of patients experience immune-related adverse events (irAEs). Autoimmune encephalitis (AE) is a rare irAE that has become a novel topic in neuroimmunology and has received increasing attention in recent years. Herein, we report a rare case of GAD65-antibody-associated AE after metastatic small cell lung cancer treatment with pembrolizumab. The patient received IVIg therapy for AE and continuous pembrolizumab therapy without suspension of tumor treatment. At 1 year follow-up, both the patient's AE symptoms and tumors were stable. We consider that the treatment of ICI-associated AE should be more individualized with prudent decision-making and should balance the tumor progression and AE treatment. In addition, we have also comprehensively reviewed the literature of ICI-associated AE, and summarized the clinical features, treatment, and prognosis of AE caused by ICI, thus broadening our understanding of the neurological complications caused by ICI.
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Zhou H, Xie X, Zhang T, Yang M, Zhou D, Yang T. Anti-GAD65 Antibody-Associated Autoimmune Encephalitis With Predominant Cerebellar Involvement Following Toripalimab Treatment: A Case Report of a Novel irAE of Toripalimab. Front Immunol 2022; 13:850540. [PMID: 35401563 PMCID: PMC8990884 DOI: 10.3389/fimmu.2022.850540] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/25/2022] [Indexed: 02/05/2023] Open
Abstract
Toripalimab (Junshi Bioscience Co., Ltd) is a new immune checkpoint inhibitor (ICI) that targets programmed cell death protein 1 (PD-1) in various cancers, including metastatic melanoma. No neurological immune-related adverse events (n-irAEs) of toripalimab have been reported, except for neuromuscular involvement. We report a case of a 63-year-old woman who presented with severe vertigo, vomiting, nystagmus, cerebellar ataxia, and cognitive impairment after toripalimab treatment for metastatic melanoma. Compared with the concomitant cognitive dysfunction and a pathological reflex involving the cerebral cortex, the signs and symptoms of cerebellar involvement were much more prominent. Anti-glutamic acid decarboxylase 65 (anti-GAD65) antibody was positive in both serum and cerebrospinal fluid (CSF). After intravenous immunoglobulin (IVIG) and methylprednisolone (IVMP) administration, the symptoms of vertigo and vomiting resolved, with cognitive impairment and cerebellar ataxia remaining. This is the first report of autoimmune encephalitis (AIE) as an n-irAE of toripalimab.
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Affiliation(s)
- Huanyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoxi Xie
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Tianyu Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Menghan Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Tianhua Yang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Fernández Madrigal L, Montero Pérez O, Rodriguez Garcés MY, Inoriza Rueda Á, Martínez Marcos FJ. Pericardial effusion with pembrolizumab. J Oncol Pharm Pract 2022; 28:1664-1670. [PMID: 35133214 DOI: 10.1177/10781552221077974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The treatment of non-small cell lung cancer (NSCLC) has profoundly changed on account of the arrival of new therapies, like immunotherapy. Within this group of drugs, those aimed at the programmed cell death-1 or programmed cell death ligand-1(PD1/PDL-1) are very relevant, for example, Pembrolizumab. Although its adverse reactions are generally mild and well tolerated, it has been associated with certain immune-related adverse events (IrAEs) than can be serious and affect any organ. CASE REPORT A 62-year-old woman diagnosed with stage IV NSCLC with a single bone metastasis and PD-L1 expression of 60% started treatment with cisplatin-pemetrexed-pembrolizumab, and maintenance with pembrolizumab. MANAGEMENT AND OUTCOME The patient attended the ER with pericardial effusion that was assumed to be a Pembrolizumab IrAE and was managed with corticosteroids. The patient fully recovered but immunotherapy was not reintroduced due to the severity of the AE. DISCUSSION The cardiovascular system is among the least affected organs by immunotoxicity, with an incidence between 0.09-0.6%. However, some authors suspect the incidence is underestimated. Median time to onset is highly variable, ranging from 6 weeks since the first dose to 2 years after discontinuation of the treatment. There are not guidelines on the most effective management of the IrAEs, but according to the pharmaceutical reference, corticosteroids should be initiated followed by a progressive reduction. If no response is obtained, another immunosuppressive agent should be added. The determination to restart immunotherapy depends on the severity of the adverse reaction, the availability of other alternative treatments, and the cancer response.
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Affiliation(s)
| | - Olalla Montero Pérez
- Unidad de Gestión Clínica Farmacia Hospitalaria, 16839Hospital Juan Ramón Jiménez, Huelva, Spain
| | | | - Ángel Inoriza Rueda
- Unidad de Gestión Clínica Oncología Médica, 16839Hospital Juan Ramón Jiménez, Huelva, Spain
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Braden J, Lee JH. Immune Checkpoint Inhibitor Induced Pericarditis and Encephalitis in a Patient Treated With Ipilimumab and Nivolumab for Metastatic Melanoma: A Case Report and Review of the Literature. Front Oncol 2021; 11:749834. [PMID: 34956874 PMCID: PMC8696256 DOI: 10.3389/fonc.2021.749834] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/16/2021] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have dramatically improved outcomes in melanoma. Common ICI toxicities have become familiar to clinicians; however, rare delayed toxicities remain challenging given the paucity of data with such presentations. We present the unique case of a 61-year-old with metastatic melanoma with two rare, delayed ICI-induced toxicities. After resection of a large symptomatic parietal metastases, this patient received two doses of combination ipilimumab and nivolumab. Five weeks following his second dose, he developed ICI-induced pericarditis with associated pericardial effusion and early signs of tamponade. Corticosteroids were not administered due to a concurrent cerebral abscess. Administration of colchicine, ibuprofen, judicious monitoring, and cessation of immunotherapy led to the complete resolution of the effusion over several weeks. Seven months following his last dose of immunotherapy, the patient developed ICI-associated grade four autoimmune encephalitis, presenting as status epilepticus. High-dose steroid initiation led to rapid clinical improvement. The patient remains in near-complete response on imaging with no recurrence of pericardial effusion and partial resolution of neurological symptoms. ICI-induced pericardial disease and encephalitis carry substantial mortality rates and prompt diagnosis and management is critical. Clinicians must therefore remain vigilant for these rare toxicities regardless of duration of drug exposure or time since cessation of therapy.
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Affiliation(s)
- Jorja Braden
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Jenny H Lee
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, NSW, Australia.,Department of Biomedical Sciences, Macquarie University, Sydney, NSW, Australia
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12
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Nersesjan V, McWilliam O, Krarup LH, Kondziella D. Autoimmune Encephalitis Related to Cancer Treatment With Immune Checkpoint Inhibitors: A Systematic Review. Neurology 2021; 97:e191-e202. [PMID: 33952651 DOI: 10.1212/wnl.0000000000012122] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/11/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine the clinical and laboratory features of immune checkpoint inhibitor (ICPI)-associated autoimmune encephalitis (ICPI-AIE), an increasingly recognized adverse event with ICPI treatment. METHODS We searched PubMed, The Cochrane Library, and Embase for ICPI-AIE cases from the first description in 2015 until January 2020 using standard bibliographic measures including PRISMA guidelines and preregistration with PROSPERO. RESULTS Thirty-nine studies met inclusion criteria, resulting in 54 patients with ICPI-AIE (mean age 58.6 years; 43% female). Common cancers included melanoma (30%) and non-small cell lung cancer (30%). Brain metastases were found in 16 patients (30%). The most frequent ICPI was nivolumab (61%). Onset of ICPI-AIE occurred after a median of 3.0 treatment cycles, but very early and late presentations were common. Nonlimbic AIE was roughly twice as frequent as limbic AIE (p < 0.05). The most common laboratory abnormalities included bitemporal fluid-attenuated inversion recovery lesions on MRI, continuous slow waves and diffuse slowing on EEG, and monocytic pleocytosis on CSF analysis. Intraneuronal antibodies were more frequent than neuronal surface antibodies and a significant predictor for lack of improvement after first-line immunotherapy (p < 0.05). CONCLUSIONS ICPI-AIE consists of a heterogenous group of conditions. Neurologists will likely encounter ICPI-AIE more often in the future, but important unresolved questions include the pathophysiologic mechanisms, the epidemiology, and the best treatment approaches associated with ICPI-AIE.
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Affiliation(s)
- Vardan Nersesjan
- From the Department of Neurology (V.N., O.M., L.-H.K., D.K.), Rigshospitalet, Copenhagen University Hospital; and Department of Clinical Medicine (D.K.), Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Oskar McWilliam
- From the Department of Neurology (V.N., O.M., L.-H.K., D.K.), Rigshospitalet, Copenhagen University Hospital; and Department of Clinical Medicine (D.K.), Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Lars-Henrik Krarup
- From the Department of Neurology (V.N., O.M., L.-H.K., D.K.), Rigshospitalet, Copenhagen University Hospital; and Department of Clinical Medicine (D.K.), Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Daniel Kondziella
- From the Department of Neurology (V.N., O.M., L.-H.K., D.K.), Rigshospitalet, Copenhagen University Hospital; and Department of Clinical Medicine (D.K.), Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
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Velasco R, Villagrán M, Jové M, Simó M, Vilariño N, Alemany M, Palmero R, Martínez-Villacampa MM, Nadal E, Bruna J. Encephalitis Induced by Immune Checkpoint Inhibitors: A Systematic Review. JAMA Neurol 2021; 78:864-873. [PMID: 33720308 DOI: 10.1001/jamaneurol.2021.0249] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Encephalitis is a severe immune-related adverse event secondary to treatment with immune checkpoint inhibitors (ICIs). The spectrum of ICI-induced encephalitis (ICI-iE) ranges from disease that resolves fully to lethal forms. Moreover, ICIs may unmask a paraneoplastic encephalitis. To our knowledge, the factors associated with ICI-iE prognosis are unknown. Objectives To evaluate the presentation of ICI-iE and to identify features helpful in assessing outcomes. Evidence Review This systematic review pooled case series from the published literature (n = 77) and medical records from 1 center (n = 5) to assess the association between the form of ICI-iE presentation and its prognosis. Eligibility criteria included references identified by searches of PubMed and Web of Knowledge databases in the English literature from June 2000 (first patient dose of ipilimumab) to April 17, 2020, that examined patients with encephalitis with presumed autoimmune etiologic features induced by ICIs. Information regarding clinical, cerebrospinal fluid, and neuroimaging (magnetic resonance imaging) features, as well as treatment given, were extracted. Findings A total of 82 patients (52 men [63%]; median age, 61.0 years [interquartile range, 52.5-70.0 years]) were included. Most patients presented with focal syndromes (39 [48%]) or meningoencephalitis (36 [44%]). Seven patients (9%) had nonclassifiable ICI-iE. Neuronal autoantibodies were detected in 23 patients with focal syndromes and 1 patient with nonclassifiable ICI-iE. Most autoantibodies were onconeuronal (17 of 24 [71%]), targeting intracellular antigens. Patients without a focal syndrome or with a negative-antibody focal syndrome had a good prognosis (49 of 55 [89%]). Among patients with autoantibodies, those with anti-glutamic acid decarboxylase or anticell surface responded to treatment and had a favorable prognosis (100%). However, patients with other autoantibodies had poor outcomes (17 of 24 [71%]). Antineuronal autoantibodies (13 of 24 [54%] vs 5 of 41 [12%]; P < .001), focal syndrome (16 of 39 [41%] vs 4 of 43 [9%]; P = .001), and abnormal magnetic resonance imaging findings (14 of 39 [36%] vs 4 of 32 [13%]; P = .02) were associated with poor outcomes. Conversely, fever (21 of 23 [91%] vs 41 of 59 [70%]; P = .04) and more inflammatory changes in cerebrospinal fluid (30 of 31 [97%] vs 21 of 33 [64%]; P = .001) were associated with a better prognosis. Conclusions and Relevance Immune checkpoint inhibitors may induce mainly 2 different encephalitic syndromes: a focal limbic or extralimbic encephalitis and a meningoencephalitis. Immune checkpoint inhibitor-induced encephalitis is associated with an overall favorable outcome, with a low rate of fatal events. An undetected preexisting paraneoplastic encephalitic syndrome may be triggered by ICIs, and this type of syndrome has the worst outcome among all the different types of ICI-induced encephalitis syndromes. Clinical presentation and systematic measurement of autoantibodies will be a helpful guide for the therapeutic strategy and for counseling regarding prognosis.
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Affiliation(s)
- Roser Velasco
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain.,Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Bellaterra, Spain
| | - Macarena Villagrán
- Neurology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain.,Fundación Pública Andaluza para la Gestión de la Investigación en Salud de Sevilla, Sevilla, Spain
| | - Maria Jové
- Thoracic Oncology Unit, Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Marta Simó
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain
| | - Noelia Vilariño
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain.,Thoracic Oncology Unit, Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Montserrat Alemany
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain
| | - Ramon Palmero
- Thoracic Oncology Unit, Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Maria Mercedes Martínez-Villacampa
- Department of Medical Oncology, Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Ernest Nadal
- Thoracic Oncology Unit, Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Jordi Bruna
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d´Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain.,Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Bellaterra, Spain
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14
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Valencia-Sanchez C, Zekeridou A. Paraneoplastic Neurological Syndromes and Beyond Emerging With the Introduction of Immune Checkpoint Inhibitor Cancer Immunotherapy. Front Neurol 2021; 12:642800. [PMID: 33897597 PMCID: PMC8062756 DOI: 10.3389/fneur.2021.642800] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 12/19/2022] Open
Abstract
Paraneoplastic neurological syndromes are more commonly seen with malignancies such as small cell lung cancer, thymoma, gynecological malignancies, and breast cancer as well as seminoma. With the introduction of immune checkpoint inhibitor (ICI) cancer immunotherapy we see an increase of autoimmune neurological complications in patients with malignancies not traditionally associated with paraneoplastic neurological syndromes, such as melanoma and renal cell carcinoma. Immune checkpoint inhibitors enhance antitumor immune responses resulting often in immune-related adverse effects that can affect any organ, including the central and peripheral nervous system, neuromuscular junction and muscle. Neurological complications are rare; neuromuscular complications are more common than central nervous system ones but multifocal neurological presentations are often encountered. The vast majority of neurological complications appear within 3 months of ICI initiation, but have been described even after ICI cessation. Neural autoantibody testing reveals autoantibodies in approximately half of the patients with CNS complications. Early suspicion and diagnosis is critical to avoid worsening and improve outcomes. Therapeutic strategies depend on the severity of the symptoms and initially typically involve discontinuation of ICI and high dose steroids. Further immunosuppression might be necessary. Outcomes are dependent on patient's characteristics and clinical presentations.
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Affiliation(s)
- Cristina Valencia-Sanchez
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Anastasia Zekeridou
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, United States
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15
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Fan S, Ren H, Zhao L, Yin J, Feng G, Wang J, Guan H. Neurological immune‐related adverse events associated with immune checkpoint inhibitors: A review of the literature. Asia Pac J Clin Oncol 2020; 16:291-298. [PMID: 32893999 DOI: 10.1111/ajco.13375] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 05/05/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Luo Zhao
- Department of Thoracic Surgery, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Jian Yin
- Department of Neurology Beijing Hospital Beijing China
| | - Guodong Feng
- Department of Neurology, Zhongshan Hospital Fudan University Shanghai China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital Capital Medical University Beijing China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
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16
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Vogrig A, Muñiz-Castrillo S, Joubert B, Picard G, Rogemond V, Marchal C, Chiappa AM, Chanson E, Skowron F, Leblanc A, Ducray F, Honnorat J. Central nervous system complications associated with immune checkpoint inhibitors. J Neurol Neurosurg Psychiatry 2020; 91:772-778. [PMID: 32312871 DOI: 10.1136/jnnp-2020-323055] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/24/2020] [Accepted: 04/08/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe the spectrum and outcome of central nervous system complications associated with immune checkpoint inhibitors (CNS-ICI). METHODS Patients with CNS-ICI were identified and their characteristics compared with ICI-related peripheral neuropathy (PN-ICI). RESULTS We identified 19 patients with CNS-ICI. The patients were receiving nivolumab (n=8), pembrolizumab (n=6), a combination of ipilimumab-nivolumab (n=3), ipilimumab-durvalumab (n=1), or atezolizumab (n=1). Underlying malignancies included non-small-cell lung cancer (n=8), melanoma (n=3), and other less common tumours (n=8). Neurological phenotypes were limbic encephalitis (n=8), meningoencephalitis (n=4) and cerebellitis (n=4). Two patients developed isolated confusion and one parkinsonism. Associated autoantibodies included onconeural (Ma2, n=7; Hu, n=1), astrocytic (glial fibrillar acidic protein, n=2) and neuronal surface (contactin-associated protein-like 2, n=1) specificities. ICIs were withheld and corticosteroid treatment was given in all cases. Five patients received intravenous immunoglobulin, two rituximab, one plasmapheresis and one infliximab. Overall, six patients died. Readministration of ICI was attempted in three patients, without further relapses. Non-small-cell lung cancer was significantly more frequent in patients with CNS-ICI (p<0.01), while melanoma and ipilimumab treatment were more common in PN-ICI (p<0.01 and p=0.01). Conversely, CNS-ICI cases were more frequently antibody-positive than PN-ICI (p<0.01) and showed a strong trend towards poorer outcome (p=0.053). CONCLUSION Three main clinical phenotypes characterise CNS complications of ICIs, each with distinct immunological background, disease course and response to treatment. Other clinical manifestations (including parkinsonism and steroid-responsive confusion) are also possible. Underlying cancers, antibody prevalence and outcome appear different from those of patients with PN-ICI.
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Affiliation(s)
- Alberto Vogrig
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Sergio Muñiz-Castrillo
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Bastien Joubert
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Geraldine Picard
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Veronique Rogemond
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Cécile Marchal
- Service de Neurologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | - Eve Chanson
- Service de Neurologie, Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France
| | | | - Amelie Leblanc
- Service de Neurologie, CHRU Cavale-Blanche, Brest, France
| | - François Ducray
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France.,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Jerome Honnorat
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Lyon, France .,Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.,University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
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17
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Hu R, Chen M, Xu Y, Wang M, Zheng K, Li X. Renal immune-related adverse events of immune checkpoint inhibitor. Asia Pac J Clin Oncol 2020; 16:305-311. [PMID: 32573099 DOI: 10.1111/ajco.13387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/13/2020] [Indexed: 12/11/2022]
Abstract
The status of immune checkpoint inhibitors (ICPIs) is raising in the treatment of malignancy for their effectiveness. The ICPIs therapy takes the risk of off-target toxicity because of immune system overactivation, including renal toxicity. It was declared that the renal toxicity was rare. However, with the increasing experience of ICPIs therapy, the renal immune-relate adverse events of ICPIs were reported more and their management was launching an enthusiastic discussion nowadays. In this review, we focused on the mechanism of ICPIs related renal irAEs (immune-related adverse events), the clinical and pathological manifestation of different forms of renal injury, and management strategies when the renal irAEs happened. Good management of irAEs might need help from Multi-Disciplinary Treatment and could promote a better clinical practice on ICPIs.
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Affiliation(s)
- Rongrong Hu
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Minjiang Chen
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Xu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Mengzhao Wang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ke Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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18
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Bas O, Ozbek A, Guven D, Aktepe O, Kılıc L, Kertmen N, Erman M. Pembrolizumab- and/or pazopanib-induced remitting seronegative symmetrical synovitis with pitting edema in a patient with renal cell carcinoma. J Oncol Pharm Pract 2019; 26:1230-1233. [PMID: 31735133 DOI: 10.1177/1078155219884113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors and angiogenesis inhibitors are novel treatment options for renal cell carcinoma and widely used in clinical practice. They are related with adverse events that occur as a consequence of immune system activation and inhibition of angiogenesis. Herein, we report a rare case of inflammatory arthritis seen in a patient treated with an anti Programmed cell death-1 pembrolizumab and an anti-vascular endothelial growth factor pazopanib. CASE REPORT A 60-year-old Caucasian male presented to our clinic with inflammatory arthritis with pitting edema. He had been started on pembrolizumab therapy for metastatic renal cell carcinoma after enrolling in the KEYNOTE-679 study. After six cycles of treatment with pembrolizumab, metastasis had been determined in the lung. Then, the patient's therapy was changed to pazopanib. While the patient was on pazopanib treatment, he noticed a gradual swelling of both hands. Rheumatoid factor, anti-nuclear antibody and anti-cyclic citrullinated peptide were negative. Joint ultrasonography revealed acute tenosynovitis and soft tissue swelling with pitting edema, and a diagnosis of remitting seronegative symmetrical synovitis with pitting edema was made. Management and outcome: He was started on 10 mg prednisolone daily. His symptoms dramatically responded to corticosteroid. He continued to take pazopanib. Then, the patient was discharged with 10 mg prednisolone daily. DISCUSSION Pembrolizumab- and/or pazopanib-induced remitting seronegative symmetrical synovitis with pitting edema can be among the rare rheumatic immune-related adverse events that clinicians may encounter as the immune check point inhibitors and anti-VEGF use increases. Corticosteroid therapy can relieve symptoms and cessation of therapy may not be necessary.
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Affiliation(s)
- Onur Bas
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Aral Ozbek
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Denizcan Guven
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Oktay Aktepe
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Levent Kılıc
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Neyran Kertmen
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mustafa Erman
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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