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O'Hare M, Guidon AC. Peripheral nervous system immune-related adverse events due to checkpoint inhibition. Nat Rev Neurol 2024; 20:509-525. [PMID: 39122934 DOI: 10.1038/s41582-024-01001-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/12/2024]
Abstract
Immune checkpoint inhibitors have revolutionized cancer therapy and are increasingly used to treat a wide range of oncological conditions, with dramatic benefits for many patients. Unfortunately, the resulting increase in T cell effector function often results in immune-related adverse events (irAEs), which can involve any organ system, including the central nervous system (CNS) and peripheral nervous system (PNS). Neurological irAEs involve the PNS in two-thirds of affected patients. Muscle involvement (immune-related myopathy) is the most common PNS irAE and can be associated with neuromuscular junction involvement. Immune-related peripheral neuropathy most commonly takes the form of polyradiculoneuropathy or cranial neuropathies. Immune-related myopathy (with or without neuromuscular junction involvement) often occurs along with immune-related myocarditis, and this overlap syndrome is associated with substantially increased mortality. This Review focuses on PNS adverse events associated with immune checkpoint inhibition. Underlying pathophysiological mechanisms are discussed, including antigen homology between self and tumour, epitope spreading and activation of pre-existing autoreactive T cells. An overview of current approaches to clinical management is provided, including cytokine-directed therapies that aim to decouple anticancer immunity from autoimmunity and emerging treatments for patients with severe (life-threatening) presentations.
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Affiliation(s)
- Meabh O'Hare
- Brigham and Women's Hospital, Division of Neuromuscular Medicine, Department of Neurology, Boston, MA, USA.
- Massachusetts General Hospital, Division of Neuromuscular Medicine, Department of Neurology, Boston, MA, USA.
| | - Amanda C Guidon
- Massachusetts General Hospital, Division of Neuromuscular Medicine, Department of Neurology, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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2
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Shibuya R, Baba K, Furuta R, Maesaka H, Hirosawa H, Bando T, Oshima A, Onoda H, Nukui T, Dougu N, Joho S, Nakatsuji Y. Liver Cancer with Overlapping Myasthenia Gravis, Myocarditis, Seronegative Autoimmune Autonomic Ganglionopathy, and Myositis Symptoms Induced by Atezolizumab. Intern Med 2024; 63:2193-2198. [PMID: 38171860 PMCID: PMC11358735 DOI: 10.2169/internalmedicine.1801-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024] Open
Abstract
An 83-year-old man with hepatocellular carcinoma developed muscle weakness, ptosis, and dyspnea 3 weeks after receiving atezolizumab. Soon after, mechanical ventilation was initiated, which was followed by marked blood pressure spikes. The levels of creatine kinase and troponin-I were significantly elevated, and acetylcholine receptor antibodies were positive. The patient was diagnosed with immune checkpoint inhibitor (ICI)-induced myositis, myasthenia gravis (MG), myocarditis, and suspected autoimmune autonomic ganglionopathy (AAG). After immunotherapy, the serum markers and blood pressure normalized, and he was weaned from the ventilator after five months. To our knowledge, this is the first reported case of AAG secondary to ICI-induced myositis, MG, and myocarditis.
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Affiliation(s)
- Ryoko Shibuya
- Department of Neurology, Faculty of Medicine, University of Toyama, Japan
| | - Kousuke Baba
- Department of Neurology, Faculty of Medicine, University of Toyama, Japan
| | - Risako Furuta
- Department of Neurology, Faculty of Medicine, University of Toyama, Japan
| | - Hiroki Maesaka
- Department of Neurology, Faculty of Medicine, University of Toyama, Japan
| | - Hiroaki Hirosawa
- Department of Neurology, Faculty of Medicine, University of Toyama, Japan
| | - Tadashi Bando
- Department of Surgery, Saiseikai Toyama Hospital, Japan
| | - Akira Oshima
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama, Japan
| | - Hiroshi Onoda
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama, Japan
| | - Takamasa Nukui
- Department of Neurology, Faculty of Medicine, University of Toyama, Japan
| | - Nobuhiro Dougu
- Department of Neurology, Faculty of Medicine, University of Toyama, Japan
| | - Shuji Joho
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama, Japan
| | - Yuji Nakatsuji
- Department of Neurology, Faculty of Medicine, University of Toyama, Japan
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Lopez-Olivo MA, Kachira JJ, Abdel-Wahab N, Pundole X, Aldrich JD, Carey P, Khan M, Geng Y, Pratt G, Suarez-Almazor ME. A systematic review and meta-analysis of observational studies and uncontrolled trials reporting on the use of checkpoint blockers in patients with cancer and pre-existing autoimmune disease. Eur J Cancer 2024; 207:114148. [PMID: 38834015 PMCID: PMC11331889 DOI: 10.1016/j.ejca.2024.114148] [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: 02/02/2024] [Revised: 05/01/2024] [Accepted: 05/29/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Cancer patients with autoimmune disease have been excluded from randomized trials of immune checkpoint blockers (ICBs). We conducted a systematic review of observational studies and uncontrolled trials including cancer patients with pre-existing autoimmune disease who received ICBs. METHODS We searched 5 electronic databases through November 2023. Study selection, data collection, and quality assessment were performed independently by 2 investigators. We performed a meta-analysis to pool incidence of immune-related adverse events (irAEs), including de novo events and flares of existing autoimmune disease, hospitalizations due to irAEs, as well as deaths. RESULTS A total of 95 studies were included (23,897 patients with cancer and preexisting autoimmune disease). The most common cancer evaluated was lung cancer (30.7 %) followed by skin cancer (15.7 %). Patients with autoimmune disease were more likely to report irAEs compared to patients without autoimmune disease (relative risk 1.3, 95 % CI 1.0 to 1.6). The pooled occurrence rate of any irAEs (flares or de novo) was 61 % (95 % CI 54 % to 68 %); that of flares was 36 % (95 % CI 30 % to 43 %), and that of de novo irAEs was 23 % (95 % CI 16 % to 30 %). Flares were mild (grade <3) in half of cases and more commonly reported in patients with psoriasis/psoriatic arthritis (39 %), inflammatory bowel disease (37 %), and rheumatoid arthritis (36 %). 32 % of the patients with irAEs required hospitalization and treatment of irAEs included corticosteroids in 72 % of the cases. The irAEs mortality rate was 0.07 %. There were no statistically significant differences in cancer response to ICBs between patients with and without autoimmune disease. CONCLUSIONS Although more patients with pre-existing autoimmune disease had irAEs, these were mild and managed with corticosteroids in most cases, with no impact on cancer response. These results suggest that ICBs can be used in these patients, but careful monitoring is required, as over a third of the patients will experience a flare of their autoimmune disease and/or require hospitalization. These findings provide a crucial foundation for oncologists to refine their monitoring and management strategies, ensuring that the benefits of ICB therapy are maximized while minimizing its risks.
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Affiliation(s)
- Maria A Lopez-Olivo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Johncy J Kachira
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - 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; Rheumatology and Rehabilitation Department, Assiut University Hospitals, Faculty of Medicine, Assiut, Egypt
| | - Xerxes Pundole
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Jeffrey D Aldrich
- Department of Medicine, Division of Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Paul Carey
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Muhammad Khan
- 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
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory Pratt
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria E Suarez-Almazor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 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
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Yu H, Wang X, Pan Y, Li H. Myasthenia gravis due to anti-PD-1 treatment for an advanced colon cancer patient: a case report and literature review. J Neurol 2024; 271:5326-5332. [PMID: 38864881 DOI: 10.1007/s00415-024-12494-y] [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: 03/11/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/13/2024]
Abstract
With the advancement of cancer treatment technologies, immunotherapy has begun to be widely utilized. Colon cancer is one of the most common types of cancer, with metastasis being a frequent occurrence in late-stage patients. Hence, immunotherapy, as an emerging and potentially effective treatment modality, merits exploration to enhance patient survival rates and clinical benefits. However, various immune-related adverse events cannot be entirely avoided. Myasthenia gravis induced by immunotherapy serves as a rare but potentially lethal adverse event, and it has been increasingly reported. Understanding the mechanisms of irAEs can aid in controlling the side effects induced by treatment. Here, we reported a case of myasthenia gravis occurring after anti-PD-1 therapy for late-stage colon cancer.
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Affiliation(s)
- Hansong Yu
- General Surgery Department, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xiaoxiao Wang
- General Surgery Department, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yuetong Pan
- General Surgery Department, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Hongyan Li
- General Surgery Department, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
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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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Malvaso A, Giglio P, Diamanti L, Gastaldi M, Vegezzi E, Pace A, Bini P, Marchioni E. Unravelling the Acute, Chronic and Steroid-Refractory Management of High-Grade Neurological Immune-Related Adverse Events: A Call to Action. Brain Sci 2024; 14:764. [PMID: 39199458 PMCID: PMC11352216 DOI: 10.3390/brainsci14080764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 07/17/2024] [Accepted: 07/25/2024] [Indexed: 09/01/2024] Open
Abstract
Rare side effects of immune-checkpoint inhibitors (ICIs) are known as neurological immune-related adverse events (n-irAEs). Typically, n-irAEs affect the peripheral nervous system, primarily presenting as myositis, polyradiculoneuropathy, or cranial neuropathy. Less commonly, they impact the central nervous system, resulting in encephalitis, meningitis, or myelitis. High-grade n-irAEs managing and recognizing remains challenging, considering the risk of mortality and long-term disability. To date, strong scientific data are lacking to support the management of high-grade clinical forms. We performed a systematic literature search, selecting all articles describing high-grade steroid-resistance n-irAEs. and we reported them in a practical review. Specifically, current recommendations advise stopping ICI use and beginning corticosteroid treatment. Our findings highlighted that in steroid-resistant n-irAEs, it should be recommended to quickly escalate to plasma exchange (PLEX) and/or intravenously immunoglobulins (IVIg), usually in association with other immunosuppressants. Furthermore, newer evidence supports the use of drugs that may specifically block inflammation without reducing the anti-tumour effect of ICIs. In this practical review, we provide new evidence regarding the therapeutic approach of high-grade n-irAEs, particularly in steroid-resistant cases. We would also stress the importance of informing the scientific community of the discrepancy between current guidelines and clinical evidence in these rare forms of pathology.
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Affiliation(s)
- Antonio Malvaso
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.M.); (P.G.)
- Neuroimmunology Research Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy;
| | - Pierpaolo Giglio
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.M.); (P.G.)
| | - Luca Diamanti
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Matteo Gastaldi
- Neuroimmunology Research Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy;
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Elisa Vegezzi
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Andrea Pace
- IRCCS Regina Elena, Istituto Nazionale Tumori, 00144 Rome, Italy;
| | - Paola Bini
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Enrico Marchioni
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
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Oskam JA, Danesh-Meyer HV. Neuro-ophthalmic complications of modern anti-cancer drugs. Graefes Arch Clin Exp Ophthalmol 2024; 262:2269-2281. [PMID: 38345654 PMCID: PMC11222285 DOI: 10.1007/s00417-023-06350-4] [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: 08/20/2023] [Revised: 12/01/2023] [Accepted: 12/18/2023] [Indexed: 07/04/2024] Open
Abstract
PURPOSE Targeted cancer therapies have been responsible for a dramatic shift in treatment strategies for cancer, and the number of drugs, classes, and indications are continually growing. Neuro-ophthalmic complications of these medications are an uncommon but important subset of adverse events which profoundly impact vision. This review aims to collate studies and reports of known neuro-ophthalmic complications of targeted therapies and describe their management. METHODS The anti-cancer drugs included in the review were any drugs targeting specific molecules involved in the cancer disease process. PubMed, EMBASE, and Web of Science were searched using the generic names of each drug and keywords of neuro-ophthalmic conditions. The prescribing information published by the US Food and Drug Administration (FDA) for each drug was also reviewed. RESULTS Several classes of targeted anti-cancer drugs were found to cause neuro-ophthalmic adverse effects. Immune checkpoint inhibitors are responsible for a raft of immune-related adverse events such as optic neuritis, ischemic optic neuropathy, PRES, and myasthenia gravis. Therapies with anti-VEGF activity can provoke posterior reversible leukoencephalopathy, which commonly presents with visual loss and can be fatal if not treated promptly. Inhibitors of BCR-ABL1, VEGF, ALK, and proteasomes have all been linked to optic nerve disorders which can have debilitating consequences for vision. CONCLUSION The neuro-ophthalmic complications of modern anti-cancer drugs can limit or necessitate the withdrawal of these life-prolonging medications. Ophthalmologists should be alert for neuro-ophthalmic complications in these medications to facilitate prompt diagnosis and treatment and reduce the risk of severe and permanent consequences.
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Affiliation(s)
- Joshua A Oskam
- School of Optometry and Vision Science, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland, Auckland, New Zealand.
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland, Auckland, New Zealand
- Department of Ophthalmology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Kaira K, Mouri A, Imai H, Yamaguchi O, Kagamu H. Clinical Issue of Myasthenia Gravis Related to Immune Checkpoint Inhibitors. Curr Oncol Rep 2024:10.1007/s11912-024-01571-0. [PMID: 38954314 DOI: 10.1007/s11912-024-01571-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Immune-related adverse events (irAEs) are pivotal in the management of immune checkpoint inhibitors (ICIs) across various human neoplasms. While common irAEs are manageable by oncologists, the detailed features of rare complications related to ICI therapy remain elusive. Among these, immune-related myasthenia gravis (irMG) stands out as a life-threatening disease. RECENT FINDINGS Research articles published in English between 2017 and 2023 were identified using the PubMed database. Forty-six relevant research studies were examined to collate information for this review. The incidence of ICI-induced MG was found to be less than 1.0%, with approximately 20-30% of irMG patients presenting with overlap syndrome involving myocarditis and myositis. The detection of acetylcholine receptor antibodies (AChR-Ab) and elevated creatinine kinase (CK) levels proved useful in identifying 50-70% and 60-80% of cases, respectively. However, the utility of muscle-specific kinase antibodies (MuSK-Ab) in detecting irMG was limited due to a low positivity rate (0-5.3%). Ptosis emerged as the most common initial symptom of irMG, with an approximate positivity rate of 80%. Recommended treatment for irMG involves high-dose steroids in conjunction with plasmapheresis or immunoglobulins to mitigate the increased mortality associated with irMG. Early initiation of immunosuppressive therapy is imperative to prevent the worsening of irMG. Furthermore, facilitating a fulfilling social life post-hospitalization is crucial. This review sheds light on the clinical aspects and management strategies pertaining to irMG.
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Affiliation(s)
- Kyoichi Kaira
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan.
| | - Atsuto Mouri
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan
| | - Hisao Imai
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan
| | - Ou Yamaguchi
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan
| | - Hiroshi Kagamu
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan
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Emile J, Cauquil C, Carpentier D, Routier E, Robert C. Fatal myasthenia gravis (MG) associated with myositis and myocarditis in a patient with pre-existing MG treated by adjuvant nivolumab for a stage III melanoma. Eur J Cancer 2024; 205:114098. [PMID: 38761774 DOI: 10.1016/j.ejca.2024.114098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Jeanne Emile
- Service of Dermatology, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Cécile Cauquil
- Department of Neurology, CHU Bicetre, APHP, Le Kremlin Bicêtre, France
| | | | - Emilie Routier
- Service of Dermatology, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Caroline Robert
- Service of Dermatology, Gustave Roussy, Université Paris Saclay, Villejuif, France.
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Hutchinson A, Eskens D, Chan A, Bhargava A, Bycroft R. Managing suspected myasthenia gravis and myositis induced by pembrolizumab in a Jehovah's Witness sarcoma patient. J Oncol Pharm Pract 2024; 30:950-953. [PMID: 38523425 DOI: 10.1177/10781552241240734] [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: 03/26/2024]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) can cause a spectrum of adverse events known as immune-related adverse events (irAEs) that resemble autoimmune responses. Immune-mediated myasthenia gravis (MG) is a rare and serious neurologic adverse event that has been associated with ICIs requiring prompt treatment. In the Jehovah's Witness population, typical management of these adverse events may not be options, and alternative treatment choices would be needed. CASE REPORT 73-year-old Jehovah's Witness patient with high-grade undifferentiated pleiomorphic sarcoma who developed immune-mediated MG approximately 4 weeks after initiation of pembrolizumab. On the day of admission, the patient presented with a three-day history of worsening ptosis, right greater than left. He was later found to be seronegative for MG. MANAGEMENT AND OUTCOME The patient required therapy with pyridostigmine, steroids, and agreed to plasma exchange (PLEX) prior to discharge. He achieved near resolution of his neurologic symptoms, and pembrolizumab was discontinued. He later underwent radical resection of the left thigh soft tissue sarcoma and superficial inguinal lymph node dissection. He is now on active surveillance. DISCUSSION While neurologic adverse events typically present 6 weeks after initiation of ICIs, MG has been reported occurring as early as 4 weeks after initiation. This rare and serious adverse event requires prompt treatment, and clinicians need to be aware of the alternative treatment options in this unique patient population. Early conversations regarding blood products and factions must be had to develop a treatment plan in accordance with the patient's personal decisions.
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Affiliation(s)
| | - Danielle Eskens
- Department of Pharmacy, UofL Health, UofL Hospital, Louisville, KY, USA
| | - Abigail Chan
- Department of Pharmacy, UofL Health, UofL Hospital, Louisville, KY, USA
| | - Anika Bhargava
- Department of Pharmacy, UofL Health, UofL Hospital, Louisville, KY, USA
| | - Ryan Bycroft
- Department of Pharmacy, UofL Health, UofL Hospital, Louisville, KY, USA
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Kampoli K, Tsamis I, Sgouros D, Katsimbri P, Koumarianou A. Paraneoplastic dermatomyositis and Stevens-Johnson syndrome related to immunotherapy. Immunotherapy 2024:1-6. [PMID: 38888430 DOI: 10.1080/1750743x.2024.2362107] [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: 03/04/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024] Open
Abstract
Paraneoplastic syndromes such as dermatomyositis, often emerge as the initial clinical manifestation across various cancer types and are characterized by the development of B-cell responses targeting cancer-cell antigens that cross-react with normal skin and muscle cells. While these syndromes may alleviate following antineoplastic intervention, their response to immunotherapy remains elusive due to the exclusion of patients with autoimmune phenomena from clinical trials. In this report, we present the case of a female patient with advanced urothelial cancer presenting with dermatomyositis, who subsequently underwent treatment with anti-PD1 immunotherapy and experienced the onset of Stevens-Johnson syndrome. We discuss these two autoimmune entities and provide a comprehensive review of the existing literature to elucidate similar associations.
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Affiliation(s)
- Katerina Kampoli
- Hematology Oncology Unit, 4th Department of Internal Medicine, Attikon University Hospital, National & Kapodistrian University of Athens, Greece
| | - Ioannis Tsamis
- Hematology Oncology Unit, 4th Department of Internal Medicine, Attikon University Hospital, National & Kapodistrian University of Athens, Greece
| | - Dimitrios Sgouros
- 2nd Department of Dermatology & Venereology, Attikon University Hospital, National & Kapodistrian University of Athens, Greece
| | - Pelagia Katsimbri
- Rheumatology Unit, 4th Department of Internal Medicine, Attikon University Hospital, National & Kapodistrian University of Athens, Greece
| | - Anna Koumarianou
- Hematology Oncology Unit, 4th Department of Internal Medicine, Attikon University Hospital, National & Kapodistrian University of Athens, Greece
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Kaminski HJ, Sikorski P, Coronel SI, Kusner LL. Myasthenia gravis: the future is here. J Clin Invest 2024; 134:e179742. [PMID: 39105625 DOI: 10.1172/jci179742] [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: 08/07/2024] Open
Abstract
Myasthenia gravis (MG) stands as a prototypical antibody-mediated autoimmune disease: it is dependent on T cells and characterized by the presence of autoantibodies targeting proteins located on the postsynaptic surface of skeletal muscle, known as the neuromuscular junction. Patients with MG exhibit a spectrum of weakness, ranging from limited ocular muscle involvement to life-threatening respiratory failure. Recent decades have witnessed substantial progress in understanding the underlying pathophysiology, leading to the delineation of distinct subcategories within MG, including MG linked to AChR or MuSK antibodies as well as age-based distinction, thymoma-associated, and immune checkpoint inhibitor-induced MG. This heightened understanding has paved the way for the development of more precise and targeted therapeutic interventions. Notably, the FDA has recently approved therapeutic inhibitors of complement and the IgG receptor FcRn, a testament to our improved comprehension of autoantibody effector mechanisms in MG. In this Review, we delve into the various subgroups of MG, stratified by age, autoantibody type, and histology of the thymus with neoplasms. Furthermore, we explore both current and potential emerging therapeutic strategies, shedding light on the evolving landscape of MG treatment.
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Affiliation(s)
| | | | | | - Linda L Kusner
- Department of Pharmacology and Physiology, George Washington University, Washington, DC, USA
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Cooksley T, Weaver J, McNamara M, Lorigan P. Immune checkpoint inhibitor-related myasthenia gravis, myositis and myocarditis: a triad but not at the same time? QJM 2024; 117:373-374. [PMID: 38229249 DOI: 10.1093/qjmed/hcae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Indexed: 01/18/2024] Open
Affiliation(s)
- T Cooksley
- The Christie NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - J Weaver
- The Christie NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - M McNamara
- The Christie NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - P Lorigan
- The Christie NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
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14
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Speranza D, Santarpia M, Luppino F, Omero F, Maiorana E, Cavaleri M, Sapuppo E, Cianci V, Pugliese A, Racanelli V, Camerino GM, Rodolico C, Silvestris N. Immune checkpoint inhibitors and neurotoxicity: a focus on diagnosis and management for a multidisciplinary approach. Expert Opin Drug Saf 2024:1-14. [PMID: 38819976 DOI: 10.1080/14740338.2024.2363471] [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: 03/22/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024]
Abstract
INTRODUCTION Although immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, the consequential over activation of the immune system is often complicated by adverse events that can affect several organs and systems, including the nervous system. The precise pathophysiology underlying neurological irAEs (n-irAEs) is not completely known. Around 3.8% of patients receiving anti-CTLA-4 agents, 6.1% of patients receiving anti-PD-1/PD-L1, and 12% of patients receiving combination therapies have n-irAEs. Most n-irAEs are low-grade, while severe toxicities have rarely been reported. in this article, we performed an updated literature search on immuno-related neurotoxicity on main medical research database, from February 2017 to December 2023. AREAS COVERED We have also compared the latest national and international guidelines on n-irAEs management with each other in order to better define patient management. EXPERT OPINION A multidisciplinary approach appears necessary in the management of oncological patients during immunotherapy. Therefore, in order to better manage these toxicities, we believe that it is essential to collaborate with neurologists specialized in the diagnosis and treatment of n-irAEs, and that a global neurological assessment, both central and peripheral, is necessary before starting immunotherapy, with regular reassessment during treatment.
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Affiliation(s)
- Desirèe Speranza
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Mariacarmela Santarpia
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Francesco Luppino
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Fausto Omero
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Enrica Maiorana
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Mariacarmela Cavaleri
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Elena Sapuppo
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Vincenzo Cianci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Alessia Pugliese
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vito Racanelli
- Centre for Medical Sciences (CISMed), University of Trento and Internal Medicine Department, Trento, Italy
| | | | - Carmelo Rodolico
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Nicola Silvestris
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
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15
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Kiaei B, Chaudhry M, Banerjee S, Brewer J, Chen Y, Khasiyev F, Guzman MA, Hayat G. Spontaneous development of myasthenia gravis and myositis following treatment with pembrolizumab: a case report. BMC Neurol 2024; 24:184. [PMID: 38824498 PMCID: PMC11143698 DOI: 10.1186/s12883-024-03684-2] [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: 11/14/2023] [Accepted: 05/20/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors are a relatively new advancement in the world of cancer therapy. As such, their adverse effects have yet to be fully understood, with only recent literature documenting autoimmune phenomena secondary to their utilization. Specific immune checkpoint inhibitors have recently been linked with the development of myasthenia gravis, which is classically known to manifest spontaneously in patients. Given the relative rarity of this presentation, the risk of misdiagnosis and subsequent mortality and morbidity is concerning. CASE PRESENTATION We discuss the case of a 73-year-old male who presented with clinical symptoms of myasthenia gravis and myositis shortly after beginning treatment with Pembrolizumab. The diagnosis of myasthenia gravis was initially missed at an outside hospital, which delayed initiation of proper treatment. CONCLUSION While the incidence of "de-novo" diseases secondary to immune checkpoint inhibitors might be increasing, guidelines regarding best treatment options do not yet exist, leaving many providers at a loss when faced with making clinical decisions surrounding patients with De novo myasthenia gravis. Thus, our goal is to underscore the importance of early recognition of this disease, and emphasize the need for a standard of care as immune checkpoint inhibitors usage becomes more prevalent.
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Affiliation(s)
- Benjamin Kiaei
- Department of Neurology, Saint Louis University Hospital, St. Louis, USA
| | - Maaria Chaudhry
- Department of Neurology, Saint Louis University Hospital, St. Louis, USA.
| | - Sumona Banerjee
- Department of Neurology, Saint Louis University Hospital, St. Louis, USA
| | - Jonathan Brewer
- Department of Neurology, Saint Louis University Hospital, St. Louis, USA
| | - Yongzhen Chen
- Department of Neurology, Saint Louis University Hospital, St. Louis, USA
| | - Farid Khasiyev
- Department of Neurology, Saint Louis University Hospital, St. Louis, USA
| | - Miguel A Guzman
- Department of Pathology, Saint Louis University Hospital, St. Louis, USA
| | - Ghazala Hayat
- Department of Pathology, Saint Louis University Hospital, St. Louis, USA
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16
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Vivas AJ, Chaudhry U, Punchayil Narayanankutty N, Lopez R, Lamarche J. Myasthenia Gravis-Like Syndrome Resulting From Immune Checkpoint Inhibitors in a Patient With Urothelial Carcinoma. Cureus 2024; 16:e60003. [PMID: 38854361 PMCID: PMC11162823 DOI: 10.7759/cureus.60003] [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: 05/09/2024] [Indexed: 06/11/2024] Open
Abstract
The widespread use of immune checkpoint inhibitors (ICIs) for the treatment of various types of cancer has led to increasing reports of associated adverse effects. The use of the ipilimumab/nivolumab/sacituzumab combination is currently under study in patients with metastatic urothelial carcinoma, given their potential synergism for immunogenic cell death. Information regarding the toxicity spectrum of this combination is lacking. Here, we describe a patient with urothelial carcinoma who had a severe multisystem autoimmune-like toxicity and myasthenia gravis-like syndrome in response to the ipilimumab/nivolumab/sacituzumab combination therapy. We also briefly describe the literature regarding the association between combined immunotherapy use and systemic and neurological autoimmunity.
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Affiliation(s)
- Alvaro J Vivas
- General Practice, Fundacion Valle del Lili/ Universidad Icesi, Cali, COL
| | - Umar Chaudhry
- Nephrology, University of South Florida Morsani College of Medicine, Tampa, USA
| | | | - Ramon Lopez
- Nephrology, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Jorge Lamarche
- Nephrology, James A. Haley Veterans' Hospital, Tampa, USA
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17
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Chen A, Chwalisz BK. Update on Neuro-ophthalmic Manifestations of Immune Checkpoint Inhibitors. Curr Neurol Neurosci Rep 2024; 24:113-122. [PMID: 38498093 DOI: 10.1007/s11910-024-01336-z] [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] [Accepted: 02/25/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI) use has been on the rise for treatment of many different malignancies. Subsequently, more has been learned about immune-related adverse events (irAEs) that occur up to 12 months after treatment. This review summarizes the latest findings and management of neuro-ophthalmic associated irAEs. RECENT FINDINGS irAEs can affect the afferent and efferent neuro-ophthalmic pathways, thereby targeting central and peripheral nervous systems. As more cases are being reported, it is becoming apparent that neuro-ophthalmic irAEs often present with atypical features when compared to their spontaneous autoimmune counterparts. These neuro-ophthalmic presentations can also be signs of a more extensive inflammatory process that spans other organ systems, such as myopathies, endocrinopathies, and paraneoplastic syndromes. Awareness of neuro-ophthalmic irAEs and their atypical presentations can lead to early detection, termination of ICI treatment, and immunosuppressant therapy initiation.
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Affiliation(s)
- Amalie Chen
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Bart K Chwalisz
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, MA, USA.
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18
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Heemelaar JC, Louisa M, Neilan TG. Treatment of Immune Checkpoint Inhibitor-associated Myocarditis. J Cardiovasc Pharmacol 2024; 83:384-391. [PMID: 37506676 PMCID: PMC10830893 DOI: 10.1097/fjc.0000000000001456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023]
Abstract
ABSTRACT Immune checkpoint inhibitors (ICIs) are a form immunotherapy where the negative regulators of host immunity are targeted, thereby leveraging the own immune system. ICIs have significantly improved cancer survival in several advanced malignancies, and there are currently more than 90 different cancer indications for ICIs. Most patients develop immune-related adverse events during ICI therapy. Most are mild, but a small subset of patients will develop severe and potentially fatal immune-related adverse events. A serious cardiovascular complication of ICI therapy is myocarditis. Although the incidence of myocarditis is low, mortality rates of up to 50% have been reported. The mainstay of ICI-associated myocarditis treatment is high-dose corticosteroids. Unfortunately, half of patients with myocarditis do not show clinical improvement after corticosteroid treatment. Also, high doses of corticosteroids may adversely impact cancer outcomes. There is an evidence gap in the optimal second-line treatment strategy. Currently, there is a paradigm shift in second-line treatment taking place from empirical corticosteroid-only strategies to either intensified initial immunosuppression where corticosteroids are combined with another immunosuppressant or targeted therapies directed at the pathophysiology of ICI myocarditis. However, the available evidence to support these novel strategies is limited to observational studies and case reports. The aim of this review is to summarize the literature, guidelines, and future directions on the pharmacological treatment of ICI myocarditis.
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Affiliation(s)
- Julius C Heemelaar
- Cardiovascular Imaging Research Center (CIRC), Department of Cardiology and Radiology, Massachusetts General Hospital, Boston, MA; and
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maria Louisa
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Department of Cardiology and Radiology, Massachusetts General Hospital, Boston, MA; and
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19
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Jayan A, Mammen AL, Suarez-Almazor ME. Immune Checkpoint Inhibitor-induced Myositis. Rheum Dis Clin North Am 2024; 50:281-290. [PMID: 38670726 PMCID: PMC11328989 DOI: 10.1016/j.rdc.2024.02.003] [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] [Indexed: 04/28/2024]
Abstract
Myositis induced by immune checkpoint inhibitors (ICIs) is an infrequent, potentially fatal, immune-related adverse event. It has higher incidence in patients who receive combination ICI therapy compared to monotherapy. Patients can present with clinical manifestation symptoms of myositis alone or in combination with myocarditis and/or myasthenia gravis, which significantly worsens the course and prognosis. Diagnosis can generally be made on the basis of clinical presentation, elevation of muscle enzymes, and electromyographic changes, but some patients may require a muscle biopsy. The first line of therapy is high-dose corticosteroids, followed by immunosuppression, plasmapheresis, or intravenous immunoglobulin in patients with severe disease.
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Affiliation(s)
- Athira Jayan
- Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Andrew L Mammen
- Department of Neurology, Johns Hopkins University School of Medicine; Department of Medicine, Johns Hopkins University School of Medicine; Muscle Disease Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 50, Room 1146, Bethesda, MD 20892, USA
| | - Maria E Suarez-Almazor
- Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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20
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Zammit F, Seront E. Neurological Adverse Events Related to Immune Checkpoint Inhibitors: A Practical Review. Pharmaceuticals (Basel) 2024; 17:501. [PMID: 38675461 PMCID: PMC11053462 DOI: 10.3390/ph17040501] [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: 03/05/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The increasing use of immune checkpoint inhibitors (ICI) in cancer therapy has brought attention to their associated neurotoxicities, termed neurological immune-related adverse events (n-irAEs). Despite their relatively rare incidence, n-irAEs pose a significant risk, potentially leading to severe, long-lasting disabilities or even fatal outcomes. This narrative review aims to provide a comprehensive overview of n-irAEs, focusing on their recognition and management. The review addresses a spectrum of n-irAEs, encompassing myositis, myasthenia gravis, various neuropathies, and central nervous system complications, such as encephalitis, meningitis, and demyelinating diseases. The key features of n-irAEs are emphasized in this review, including their early onset after initiation of ICIs, potential association with non-neurological irAEs and/or concurrent oncological response, the significance of ruling out other etiologies, and the expected improvement upon discontinuation of ICIs and/or immunosuppression. Furthermore, this review delves into considerations for ICI re-challenge and the intricate nature of n-irAEs within the context of pre-existing autoimmune and paraneoplastic syndromes. It underscores the importance of a multidisciplinary approach to diagnosis and treatment, highlighting the pivotal role of severity grading in guiding treatment decisions.
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Affiliation(s)
| | - Emmanuel Seront
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
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21
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Qin Y, Chen S, Gui Q, Zhang T, Li Y, Du Z, Lv Y, Du X, Hu Y, Liu Z. Prognosis of immune checkpoint inhibitor-induced myasthenia gravis: a single center experience and systematic review. Front Neurol 2024; 15:1372861. [PMID: 38633537 PMCID: PMC11022771 DOI: 10.3389/fneur.2024.1372861] [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: 01/18/2024] [Accepted: 03/07/2024] [Indexed: 04/19/2024] Open
Abstract
Background Immune checkpoint inhibitors (ICI)-induced myasthenia gravis (MG) is an uncommon but potentially fatal neurotoxicity. We aim to help physicians familiarize themselves with the clinical characteristics of ICI-induced MG, facilitating early diagnosis and prompt intervention. Methods We searched the Chinese People's Liberation Army General Hospital medical record system from January 2017 to August 2023 for patients diagnosed with ICI-induced MG. We systematically reviewed the literature until August 2023 to identify all similar patients. We collected clinical information on these patients. Results 110 patients were identified, 9 from our institution and 101 from case reports. In our institution, Median age was 66 years (range: 49-79 years). 6 were males. The most common was lung cancer (n = 4). All patients had no previous history of MG and received PD-1 or PD-L1 inhibitors. The median time from ICI initiation to first MG symptoms was 4 weeks (range: 2-15 weeks). ICIs were discontinued in all patients. Most patients initially received high-dose corticosteroids, and their symptoms improved. Some patients are discharged with corticosteroids maintenance therapy. In addition, 55 patients (50%) with concomitant myositis and/or myocarditis and MG-induced mortality were more common in the myositis and/or myocarditis group (10.9% vs. 34.5%, p = 0.016). Overlap of myositis with MG (OR = 3.148, p = 0.009) and anti-AChR antibody positivity (OR = 3.364, p = 0.005) were both significantly associated with poor outcomes. Conclusion Our study reveals the prognosis of ICI-induced MG and suggests that myositis and/or myocarditis are severe comorbidities of ICI-induced MG, emphasizing the importance of early diagnosis and clinical intervention.
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Affiliation(s)
- Yuhui Qin
- Department of Medical Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Siyuan Chen
- Department of Medical Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Qian Gui
- School of Medicine, Jianghan University, Wuhan, China
| | - Teng Zhang
- Department of Oncology, The 983rd Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Yanan Li
- Department of Medical Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Zhijuan Du
- Department of Medical Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Yahui Lv
- Department of Medical Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Xiangyu Du
- Department of Medical Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Yi Hu
- Department of Medical Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Zhefeng Liu
- Department of Medical Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
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22
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Gullapalli M, Arulprakash N, Safar M, Kocurek E. Case of Immune Checkpoint Inhibitor Induced Myasthenia Gravis. Cureus 2024; 16:e58651. [PMID: 38770481 PMCID: PMC11104708 DOI: 10.7759/cureus.58651] [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: 04/19/2024] [Indexed: 05/22/2024] Open
Abstract
An 85-year-old man was diagnosed with hepatocellular carcinoma (HCC) and was initially treated with transarterial chemoembolization (TACE) and sorafenib. He was then switched to nivolumab and ipilimumab in view of sorafenib intolerance and disease progression. Subsequently, he developed dysphagia and generalized dyspnea culminating in hypercapnic respiratory failure requiring intubation. After an extensive workup, the etiology of his fluctuating respiratory issues was narrowed down to a likely neuromuscular process. Although antibodies to acetylcholine receptors (anti-AChR Ab) were negative, he was treated with high-dose steroids due to clinical concern for Immune Checkpoint Inhibitor (ICI) neurotoxicity. His recovery post immune suppression and absence of recurrence after ICI cessation suggested the possibility of this being an ICI neurotoxicity manifesting with myasthenic symptoms. Incidentally, he also had evidence of aseptic meningitis on cerebrospinal fluid analysis further strengthening this diagnosis. This case illustrates the importance of early recognition of ICI toxicity which will in turn lead to initiating treatments sooner and also decreasing the length of illness.
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Affiliation(s)
- Manoja Gullapalli
- Internal Medicine - Pediatrics, University of Arkansas for Medical Sciences, Little Rock, USA
| | | | - Mazin Safar
- Hematology and Medical Oncology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Emily Kocurek
- Medicine, Division of Pulmonary and Critical Care, University of Arkansas for Medical Sciences, Little Rock, USA
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23
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McCombe JA, Sechi E, Zekeridou A. Neurologic manifestations of autoimmunity with immune checkpoint inhibitors. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:449-465. [PMID: 38494296 DOI: 10.1016/b978-0-12-823912-4.00024-4] [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: 03/19/2024]
Abstract
Immune checkpoint inhibitors (ICIs) are cancer immunotherapies that enhance the body's own immune system to treat cancer. ICI treatment, however, can cause immune-related adverse events (irAEs) that can affect any organ, resulting in significant morbidity and mortality. Neurologic irAEs (nirAEs) are rare and can affect the peripheral nervous system more commonly than the central nervous system. Treatment is dependent on the severity of the neurologic manifestations and often includs discontinuation of the ICI and initiation of steroid therapy as the first line; other treatments have also been used. NirAEs and cardiac irAEs have higher fatality rates underlying the importance of early recognition and appropriate management. This chapter reviews the clinical manifestations of neurologic immune-related adverse events associated with ICI treatment as well as diagnostic and therapeutic modalities.
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Affiliation(s)
- Jennifer A McCombe
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States.
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24
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Ameri M, Al-Zubidi N, Lee AG. Immune checkpoint monoclonal antibody-related adverse effects in neuro-ophthalmology. Saudi J Ophthalmol 2024; 38:25-28. [PMID: 38628415 PMCID: PMC11017004 DOI: 10.4103/sjopt.sjopt_296_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 04/19/2024] Open
Abstract
Immunotherapy has renovated the field of oncology. Usually, cancer is treated by surgery, chemotherapy, and radiation. Immunotherapy is a promising treatment that harnesses the patient's own immune system to target cancer. Immune checkpoint inhibitors (ICIs) have proven to be a promising treatment avenue for managing cancer; however, their use had been associated with a unique spectrum of adverse side effects called immune-related adverse events (irAEs). As ICIs become increasingly relevant in cancer management, it is crucial to address these irAEs affecting various systems in the body, including the skin, liver, gastrointestinal tract, endocrine system, and the eye. Ocular toxicity and sight-threatening events are among the reported irAEs, impacting diverse ocular tissues. The most commonly reported ocular irAEs (OirAEs) are blurred vision, conjunctivitis, ocular surface disease uveitis, scleritis, and retinopathy. Nevertheless, the frequency and severity of these OirAEs can vary, even within the same class of ICIs. Thus, OirAEs can significantly impact the quality of life and patient compliance. Therefore, we aim to comprehensively analyze uncommon and severe ICI-related OirAEs associated with lung cancer by providing a comprehensive and updated review of immune checkpoint monoclonal antibody-related adverse effects in neuro-ophthalmology irAEs. Through a review of the relevant literature, we intend to illustrate the epidemiology, clinical characteristics, contributory factors, diagnosis, and management of ICI-associated ocular side effects. We will also discuss guidelines and best practice strategies for the prevention, monitoring, and management of these OirAEs.
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Affiliation(s)
- May Ameri
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nagham Al-Zubidi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew G. Lee
- Department of Ophthalmology, The Methodist Hospital, Houston, TX, USA
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25
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Altan M, Li QZ, Wang Q, Vokes NI, Sheshadri A, Gao J, Zhu C, Tran HT, Gandhi S, Antonoff MB, Swisher S, Wang J, Byers LA, Abdel-Wahab N, Franco-Vega MC, Wang Y, Lee JJ, Zhang J, Heymach JV. Distinct patterns of auto-reactive antibodies associated with organ-specific immune-related adverse events. Front Immunol 2023; 14:1322818. [PMID: 38152395 PMCID: PMC10751952 DOI: 10.3389/fimmu.2023.1322818] [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: 10/16/2023] [Accepted: 11/29/2023] [Indexed: 12/29/2023] Open
Abstract
The roles of preexisting auto-reactive antibodies in immune-related adverse events (irAEs) associated with immune checkpoint inhibitor therapy are not well defined. Here, we analyzed plasma samples longitudinally collected at predefined time points and at the time of irAEs from 58 patients with immunotherapy naïve metastatic non-small cell lung cancer treated on clinical protocol with ipilimumab and nivolumab. We used a proteomic microarray system capable of assaying antibody reactivity for IgG and IgM fractions against 120 antigens for systemically evaluating the correlations between auto-reactive antibodies and certain organ-specific irAEs. We found that distinct patterns of auto-reactive antibodies at baseline were associated with the subsequent development of organ-specific irAEs. Notably, ACHRG IgM was associated with pneumonitis, anti-cytokeratin 19 IgM with dermatitis, and anti-thyroglobulin IgG with hepatitis. These antibodies merit further investigation as potential biomarkers for identifying high-risk populations for irAEs and/or monitoring irAEs during immunotherapy treatment. Trial registration ClinicalTrials.gov identifier: NCT03391869.
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Affiliation(s)
- Mehmet Altan
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Quan-Zhen Li
- Department of Immunology, UT Southwestern Medical Center, Dallas, TX, United States
| | - Qi Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Natalie I. Vokes
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jianjun Gao
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Chengsong Zhu
- Department of Immunology, UT Southwestern Medical Center, Dallas, TX, United States
| | - Hai T. Tran
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Saumil Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mara B. Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Stephen Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jing Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lauren A. Byers
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Noha Abdel-Wahab
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Maria C. Franco-Vega
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Yinghong Wang
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - J. Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jianjun Zhang
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - John V. Heymach
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Otsuka S, Horiuchi K, Nagano Y, Kimura N, Hiraoka K. Myasthenia Gravis Associated With Pembrolizumab for Relapsed Lung Cancer After Thymoma Resection. Cureus 2023; 15:e49767. [PMID: 38161528 PMCID: PMC10757735 DOI: 10.7759/cureus.49767] [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: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Immunotherapy has demonstrated clinical efficacy in patients with thymic epithelial tumors; however, there is the potential risk of serious immune-related adverse events (irAEs). Here, we report a case of myasthenia gravis (MG) associated with pembrolizumab treatment that developed after thymoma resection in a patient with lung adenocarcinoma. Symptoms of MG occurred 16 days after pembrolizumab administration and progressed rapidly, necessitating mechanical ventilation and tracheostomy. Even after tumor resection, careful monitoring is crucial for patients with thymic tumors being managed with immune checkpoint therapy, particularly regarding the development of severe irAEs.
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Affiliation(s)
- Shinya Otsuka
- Surgery, National Hospital Organization Hakodate National Hospital, Hakodate, JPN
| | | | - Yutaro Nagano
- Respiratory Medicine, Hakodate Municipal Hospital, Hakodate, JPN
| | - Noriko Kimura
- Diagnostic Pathology, National Hospital Organization Hakodate National Hospital, Hakodate, JPN
| | - Kei Hiraoka
- Surgery, National Hospital Organization Hakodate National Hospital, Hakodate, JPN
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Takahashi S, Okabayashi K, Soejima I, Oniki A, Ishihara S, Tomimitsu H. Pembrolizumab-induced Myopathy with Anti-striated Muscle Antibodies Successfully Treated by Plasma Exchange. Intern Med 2023; 62:3525-3530. [PMID: 38044116 PMCID: PMC10749821 DOI: 10.2169/internalmedicine.1222-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/12/2023] [Indexed: 12/05/2023] Open
Abstract
A 70-year-old woman with advanced endometrial cancer developed right ptosis and muscle weakness in the right quadriceps after pembrolizumab administration. Serum creatine kinase (CK) levels were elevated, and anti-striated muscle antibodies were positive. On magnetic resonance imaging, the right vastus lateral muscle showed an abnormal signal. She was diagnosed with pembrolizumab-induced myopathy. We initiated plasma exchange (PE), and the ptosis immediately resolved. We then introduced oral corticosteroids, which improved her muscle weakness. We were able to rapidly diagnose her with ocular symptoms and serum CK level elevation. The early initiation of PE might prevent the exacerbation of pembrolizumab-induced myopathy.
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Affiliation(s)
| | | | - Itsuki Soejima
- Department of Neurology, JA Toride Medical Center, Japan
| | - Ayako Oniki
- Department of Neurology, JA Toride Medical Center, Japan
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Aung WY, Lee CS, Morales J, Rahman H, Seetharamu N. Safety and Efficacy of Immune Checkpoint Inhibitors in Cancer Patients and Preexisting Autoimmune Disease: A Systematic Review and Meta-Analysis in Non-Small-Cell Lung Cancer. Clin Lung Cancer 2023; 24:598-612. [PMID: 37328320 DOI: 10.1016/j.cllc.2023.05.006] [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: 03/24/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Cancer patients with preexisting autoimmune diseases (AID) have been traditionally excluded from clinical trials of immune checkpoint inhibitors (ICI) due to concerns for toxicity. As indications for ICI expand, more data are needed on the safety and efficacy of ICI treatment in cancer patients with AID. METHODS We systematically searched for studies consisting of NSCLC, AID, ICI, treatment response, and adverse events. Outcomes of interest include incidence of autoimmune flare, irAE, response rate, and ICI discontinuation. Study data were pooled using random-effects meta-analysis. RESULTS Data were extracted from 24 cohort studies, consisting of 11,567 cancer patients (3774 NSCLC patients and 1157 with AID). Pooled analysis revealed an AID flare incidence of 36% (95% CI, 27%-46%) in all cancers and 23% (95% CI, 9%-40%) in NSCLC. Preexisting AID was associated with an increased risk of de novo irAE in all cancer patients (RR 1.38, 95% CI, 1.16-1.65) and NSCLC patients (RR 1.51, 95% CI, 1.12-2.03). There was no difference in de novo grade 3 to 4 irAE and tumor response between cancer patients with and without AID. However, in NSCLC patients, preexisting AID was associated with a 2-fold increased risk of de novo grade 3 to 4 irAE (RR 1.95, 95% CI, 1.01-3.75) but also better tumor response in achieving a complete or partial response (RR 1.56, 95% CI, 1.19-2.04). CONCLUSIONS NSCLC patients with AID are at a higher risk of grade 3 to 4 irAE but are more likely to achieve treatment response. Prospective studies focused on optimizing immunotherapeutic strategies are needed to improve outcomes for NSCLC patients with AID.
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Affiliation(s)
- Wint Yan Aung
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Chung-Shien Lee
- Department of Clinical Pharmacy Practice, St. John's University College of Pharmacy and Health Sciences, Queens, NY
| | - Jaclyn Morales
- Department of Clinical Medical Library, North Shore University Hospital, Manhasset, NY
| | - Husneara Rahman
- Institute of Health System Science, Feinstein Institutes for Medical Research Biostatistics Unit, Manhasset, NY
| | - Nagashree Seetharamu
- Division of Medical Oncology and Hematology, Zuckerberg Cancer Institute, Northwell Health, New Hyde Park, NY.
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Kang Y, Zhen H, Ma N, Zhao H, Cao B. Encephalitis in a patient with hypopharynx cancer treated with immune checkpoint inhibitors and radiotherapy: a case report and review of the literature. J Cancer Res Clin Oncol 2023; 149:16239-16246. [PMID: 37676267 PMCID: PMC10620264 DOI: 10.1007/s00432-023-05328-3] [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: 07/15/2023] [Accepted: 08/21/2023] [Indexed: 09/08/2023]
Abstract
Hypopharyngeal cancer (HPC) has one of the most unfavorable prognoses among head and neck squamous cell carcinomas. Immunotherapy in combination with chemotherapy, the same as conventional induction chemotherapy, has emerged as a vital part of the induction therapy protocol for HPC. Meanwhile, the incidence of immune-related adverse events is increasing. In this light, we present the first reported case of immune-associated encephalitis in a patient with hypopharyngeal cancer treated with Camrelizumab (a PD-1 inhibitor). After receiving immunotherapy combined with chemotherapy as induction therapy, along with concurrent chemoradiotherapy, the patient presented with symptoms of fatigue, tremors, drowsiness, and an abnormal signal in the right temporal lobe as shown on a brain magnetic resonance imaging (MRI). Despite the minor elevation in protein and IgG index observed in the lumbar puncture, there is no evidence of abnormal autoantibodies or evidence of pathogenic infection. Following a thorough multidisciplinary consultation, the patient is suspected to be afflicted with immune-related autoimmune encephalitis. Intravenous methylprednisolone was prescribed as an empirical treatment at an initial dosage of 120 mg/day for 3 days, followed by steroid tapering. Finally, the patient experienced complete neurologic and radiographic (brain MRI) recovery. This case serves as a critical reminder that encephalitis is a potential diagnosis that should never be overlooked in patients undergoing immunotherapy who present with abnormal signs of the brain. The timely diagnosis and initiation of immunosuppressive therapy are key components of treating ICI-associated encephalitis.
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Affiliation(s)
- Yan Kang
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Hongchao Zhen
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Nina Ma
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Hong Zhao
- Department of Radiotherapy, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Bangwei Cao
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China.
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Aoun R, Gratch D, Kaminetzky D, Kister I. Immune Checkpoint Inhibitors in Patients with Pre-existing Neurologic Autoimmune Disorders. Curr Neurol Neurosci Rep 2023; 23:735-750. [PMID: 37870664 DOI: 10.1007/s11910-023-01306-x] [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] [Accepted: 09/11/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE OF REVIEW The use of immune checkpoint inhibitors (ICIs) for oncologic indications is associated with immune-related adverse events (irAEs). Patients with pre-existing autoimmune diseases are at increased risk of irAEs and have largely been excluded from clinical trials of ICIs. Therefore, there is limited data on the safety of safety of ICIs in patients with pre-existing neurologic autoimmune diseases (nAIDs) such as myasthenia gravis and multiple sclerosis. This review aims to synthesize the literature on the post-marketing experience with ICI in patients with pre-existing nAID and to discuss possible strategies for mitigating the risk of post-ICI nAID relapses. RECENT FINDINGS Patients with pre-existing myasthenia gravis (MG), myositis, and paraneoplastic encephalitis appear highly susceptible to neurologic relapses of their underlying neurologic disorder following ICI initiation; these relapses can cause considerable morbidity and mortality. In patients with multiple sclerosis (MS), the risk and severity of MS relapses following ICI appears to be relatively lower compared to MG. Preliminary evidence suggests that older MS patients with no recent focal neuroinflammatory activity may be safely treated with ICI. Among the several case reports of ICI in patients with a history of Guillain-Barre syndrome (GBS), neurologic worsening was only recorded in one patient who was in the acute phase of GBS at the time of ICI start. Initiating an ICI in a patient with pre-existing nAID involves a complex risk-benefit discussion between the patient, their oncologist, and neurologist. Relevant issues to consider before ICI include the choice of disease-modifying therapy for nAID (if any) and strategies for promptly identifying and managing nAID relapses should they occur. Currently, the literature consists mainly of case reports and case series, subject to publication bias. Prospective studies of ICI in patients with nAID are needed to improve the level of evidence.
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Affiliation(s)
- Raissa Aoun
- Department of Neurology, NYU Grossman School of Medicine, 550 1st Ave, New York, NY, 10016, USA
| | - Daniel Gratch
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, 5 East 98th St, New York, NY, 10029, USA
| | - David Kaminetzky
- Department of Oncology, NYU Grossman School of Medicine, 550 1st Ave, New York, NY, 10016, USA
| | - Ilya Kister
- NYU Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Grossman School of Medicine, 240 East 38th St, New York, NY, 10016, USA.
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Parvathareddy V, Selamet U, Sen AA, Mamlouk O, Song J, Page VD, Abdelrahim M, Diab A, Abdel-Wahab N, Abudayyeh A. Infliximab for Treatment of Immune Adverse Events and Its Impact on Tumor Response. Cancers (Basel) 2023; 15:5181. [PMID: 37958355 PMCID: PMC10649345 DOI: 10.3390/cancers15215181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Background: Immune-related adverse events (irAEs) challenge the use of immune checkpoint inhibitors (ICIs). We performed a retrospective study to evaluate response to infliximab for immune-related adverse event management, and infliximab's effect on progression-free survival (PFS) and overall survival (OS) with a focus on melanoma and genitourinary cancers. Methods: We retrospectively reviewed records of all cancer patients exposed to infliximab after immune checkpoint inhibitor (ICI) treatment from 2004 to 2021 at the MD Anderson Cancer Center. Survival was assessed utilizing the Kaplan-Meier method. Univariate and multivariate logistic regression was utilized to evaluate predictors of infliximab response, OS, and PFS. Results: We identified 185 cancer patients (93 melanoma and 37 genitourinary cancers) treated with ICI and who received infliximab to treat irAEs. Within 3 months of treatment initiation, 71% of the patients responded to infliximab, 27% had no response, and 2% had unknown response. Among different irAEs, colitis was associated with increased response to infliximab at 3 months, irrespective of the type of malignancy. We evaluated best tumor response before and after infliximab in the entire cohort and again in the melanoma and genitourinary (GU); the findings were similar in the melanoma cohort and the entire cohort, where best tumor response before and after infliximab was not significantly different. In the melanoma cohort, acute kidney injury (AKI) was associated with increased risk of death, p = 0.0109, and having response to infliximab was associated with decreased risk of death, p = 0.0383. Interestingly in GU cancer patients, myositis was associated with increased risk of death, p = 0.0041, and having a response to infliximab was marginally associated with decreased risk of death, p = 0.0992. As regards PFS, in a multivariate Cox regression model, having a history of cardiovascular disease remained significantly associated with shorter PFS in the melanoma cohort. For patients with GU cancers, response to infliximab was associated with longer PFS. Conclusions: Our study is among the largest retrospective analyses of infliximab use for irAE management. Patients with colitis were the best responders to infliximab. AKI before initiation of infliximab in the melanoma subcohort and myositis in GU subcohort are associated with higher risk of death. Our results indicate no association between infliximab and cancer progression with the exception of genitourinary cancers.
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Affiliation(s)
| | - Umut Selamet
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA;
| | - Aditi A. Sen
- Department of Nephrology, Baylor College of Medicine, Houston, TX 77030, USA; (V.P.); (A.A.S.)
| | - Omar Mamlouk
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Unit 1468, 1400 Pressler Street, Houston, TX 77030, USA; (O.M.); (V.D.P.)
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Valda D. Page
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Unit 1468, 1400 Pressler Street, Houston, TX 77030, USA; (O.M.); (V.D.P.)
| | - Maen Abdelrahim
- Institute of Academic Medicine and Weill Cornell Medical College, Houston Methodist Cancer Center, Houston, TX 77479, USA;
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.D.); (N.A.-W.)
| | - Noha Abdel-Wahab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.D.); (N.A.-W.)
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Rheumatology and Rehabilitation Department, Assiut University Hospitals, Faculty of Medicine, Assiut 71515, Egypt
| | - Ala Abudayyeh
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Unit 1468, 1400 Pressler Street, Houston, TX 77030, USA; (O.M.); (V.D.P.)
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Genta S, Lajkosz K, Yee NR, Spiliopoulou P, Heirali A, Hansen AR, Siu LL, Saibil S, Stayner LA, Yanekina M, Sauder MB, Keshavarzi S, Salawu A, Vornicova O, Butler MO, Bedard PL, Razak ARA, Rottapel R, Chruscinski A, Coburn B, Spreafico A. Autoimmune PaneLs as PrEdictors of Toxicity in Patients TReated with Immune Checkpoint InhibiTors (ALERT). J Exp Clin Cancer Res 2023; 42:276. [PMID: 37865776 PMCID: PMC10589949 DOI: 10.1186/s13046-023-02851-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/05/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Immune-checkpoint inhibitors (ICI) can lead to immune-related adverse events (irAEs) in a significant proportion of patients. The mechanisms underlying irAEs development are mostly unknown and might involve multiple immune effectors, such as T cells, B cells and autoantibodies (AutoAb). METHODS We used custom autoantigen (AutoAg) microarrays to profile AutoAb related to irAEs in patients receiving ICI. Plasma was collected before and after ICI from cancer patients participating in two clinical trials (NCT03686202, NCT02644369). A one-time collection was obtained from healthy controls for comparison. Custom arrays with 162 autoAg were used to detect IgG and IgM reactivities. Differences of median fluorescent intensity (MFI) were analyzed with Wilcoxon sign rank test and Kruskal-Wallis test. MFI 500 was used as threshold to define autoAb reactivity. RESULTS A total of 114 patients and 14 healthy controls were included in this study. irAEs of grade (G) ≥ 2 occurred in 37/114 patients (32%). We observed a greater number of IgG and IgM reactivities in pre-ICI collections from patients versus healthy controls (62 vs 32 p < 0.001). Patients experiencing irAEs G ≥ 2 demonstrated pre-ICI IgG reactivity to a greater number of AutoAg than patients who did not develop irAEs (39 vs 33 p = 0.040). We observed post-treatment increase of IgM reactivities in subjects experiencing irAEs G ≥ 2 (29 vs 35, p = 0.021) and a decrease of IgG levels after steroids (38 vs 28, p = 0.009). CONCLUSIONS Overall, these results support the potential role of autoAb in irAEs etiology and evolution. A prospective study is ongoing to validate our findings (NCT04107311).
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Affiliation(s)
- Sofia Genta
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Katherine Lajkosz
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Noelle R Yee
- Toronto General Research Institute, University Health Network Toronto, Toronto, ON, Canada
| | - Pavlina Spiliopoulou
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Alya Heirali
- Toronto General Research Institute, University Health Network Toronto, Toronto, ON, Canada
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lillian L Siu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sam Saibil
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lee-Anne Stayner
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Maryia Yanekina
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Maxwell B Sauder
- Division of Dematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sareh Keshavarzi
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Abdulazeez Salawu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Olga Vornicova
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marcus O Butler
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Albiruni R Abdul Razak
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Robert Rottapel
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | | | - Bryan Coburn
- Toronto General Research Institute, University Health Network Toronto, Toronto, ON, Canada
| | - Anna Spreafico
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada.
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Kitazaki Y, Yamamura O, Usui K, Ueno A, Sanada S, Sasaki H, Endo Y, Enomoto S, Ikawa M, Nakamoto Y, Hamano T. Anti-Kv1.4 Antibody-positive Nivolumab-induced Myasthenia Gravis and Myositis Presenting with Bilateral Ptosis and Demonstrating Different Pathophysiologies. Intern Med 2023; 62:3013-3020. [PMID: 37839874 PMCID: PMC10641203 DOI: 10.2169/internalmedicine.0739-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/21/2022] [Indexed: 10/17/2023] Open
Abstract
Nivolumab blocks inhibitors of T-cell activation and restores antitumor immunity but promotes T-cell activity in host tissues by blocking inhibition of the T-cell function, resulting in immune-related adverse effects. We herein report an 80-year-old man presenting with nivolumab-related myasthenia gravis with anti-muscular voltage-gated potassium channel-complex (Kv1.4) antibodies. On day 29 after nivolumab administration, he simultaneously developed rapidly progressing right ptosis and left facial paralysis. Nivolumab administration was discontinued. He subsequently presented with bulbar paralysis, dyspnea, and muscle weakness and received intravenous immunoglobulin, methylprednisolone, and plasma exchange. The severity of nivolumab-related myasthenia gravis with anti-Kv1.4 antibodies presented with diverse clinical findings.
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Affiliation(s)
- Yuki Kitazaki
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Osamu Yamamura
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Community Medicine, Faculty of Medical Science, University of Fukui, Japan
| | - Kojiro Usui
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Asako Ueno
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
| | - Sayaka Sanada
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Hirohito Sasaki
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Yoshinori Endo
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Soichi Enomoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Advanced Medicine for Community Healthcare, Faculty of Medical Sciences, University of Fukui, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tadanori Hamano
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Aging and Dementia, Faculty of Medical Sciences, University of Fukui, Japan
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Kong Q, Wang H, Ren X, Zhuo Y, Peng J. Analysis on the risk of myasthenia gravis related to immune checkpoint inhibitors based on the US FDA Adverse Event Reporting System. Cancer Med 2023; 12:19491-19499. [PMID: 37724594 PMCID: PMC10587957 DOI: 10.1002/cam4.6559] [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: 01/02/2023] [Revised: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVE To evaluate the risk of myasthenia gravis (MG) associated with immune checkpoint inhibitors (ICI). METHODS Adverse event (AE) reports related to MG, myasthenic syndrome, and MG crisis for durvalumab, atezolizumab, pembrolizumab, nivolumab, avelumab, and ipilimumab in the US FDA Adverse Event Reporting System (FAERS) from Q1 2004 to Q3 2022 were collected. The proportional reporting odds ratio (PRR) method was used to evaluate the correlation between the six drugs and the three AEs. Statistical significance was defined as having reports ≥3, PRR ≥ 2, and chi-square (χ2 ) ≥ 4. RESULTS A total of 36, 78, 276, 380, 5, and 53 AE reports were collected for durvalumab, atezolizumab, pembrolizumab, nivolumab, avelumab, and ipilimumab, respectively. For myasthenic syndrome, the PRR values reflecting the correlation with the drugs were 27.83 (χ2 = 102.66), 26.20 (χ2 = 235.67), 44.17 (χ2 = 1313.98), 32.09 (χ2 = 1229.54), 21.31 (χ2 = 151.15), and 0 for durvalumab, atezolizumab, pembrolizumab, nivolumab, avelumab, and ipilimumab, respectively. For MG, the PRR values reflecting the correlation with the drugs were 24.21 (χ2 = 682.04), 18.34 (χ2 = 900.27), 39.32 (χ2 = 7945.15), 26.93 (χ2 = 6636.45), 14.73 (χ2 = 566.47), and 15.69 (χ2 = 54.77) for durvalumab, atezolizumab, pembrolizumab, nivolumab, avelumab, and ipilimumab, respectively. For MG crisis, there were no data for durvalumab, atezolizumab, avelumab, and ipilimumab; the PRR values reflecting the correlation with the drugs were 16.54 (χ2 = 225.23) and 9.20 (χ2 = 119.14) for pembrolizumab and nivolumab, respectively. All six drugs were statistically correlated with their corresponding AEs. CONCLUSIONS ICI may lead to ICIs-associated MG during therapy. Analysis of FAERS data identified signals for AEs of MG with ICI regimens. Practitioners should consider the factors that may increase the likelihood of MG. The findings support a continued surveillance and risk factor identification.
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Affiliation(s)
- Qingli Kong
- Phase I Clinical Trial Laboratory Affiliated Hospital of Jining Medical UniversityJiningShandongChina
| | - Hui Wang
- Department of PharmacyAffiliated Hospital of Jining Medical UniversityJiningShandongChina
| | - Xiaolei Ren
- Medical Big Data CenterAffiliated Hospital of Jining Medical UniversityJiningShandongChina
| | - Yue Zhuo
- Department of PharmacyAffiliated Hospital of Jining Medical UniversityJiningShandongChina
| | - Jing Peng
- Department of PharmacyAffiliated Hospital of Jining Medical UniversityJiningShandongChina
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Hundsberger T, Schreiner B, Roth P. Immune checkpoint inhibitors induced side effects of the peripheral nervous system. Curr Opin Neurol 2023; 36:427-431. [PMID: 37639489 DOI: 10.1097/wco.0000000000001188] [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: 08/31/2023]
Abstract
PURPOSE OF REVIEW This review highlights recent knowledge on the diagnosis and treatment of immune checkpoint inhibitor-induced neurological side effects (irNAE) focussing on the neuromuscular system. RECENT FINDINGS irNAEs mainly resemble sporadic neuromuscular autoimmune diseases and paraneoplastic neurological syndromes. However, neurological symptoms may be unspecific (muscle weakness, fatigue) in the oncological setting and carry the risk of misdiagnosis and delayed therapeutic intervention. The role of disease-specific neuromuscular autoantibodies in the diagnosis is controversial as preexisting autoantibodies may otherwise be present before immune checkpoint inhibitor (ICI) treatment without clinical symptoms and may not develop in case of irNAE manifestation. A new necrotising form of myositis (irMyositis) has been described presenting with facial weakness and ptosis mimicking myasthenia gravis. It comes along with a high rate of severe myocarditis accounting for a triad overlap syndrome (myasthenia/myositis/myocarditis). The role of modern biologicals in the treatment of irNAEs has to be determined. SUMMARY irNAEs are rare but carry the risk of permanent morbidity and mortality. Early suspicion and diagnosis are key to prevent neurological sequelae. Beyond interruption of ICI administration, treatment corresponds to sporadic autoimmune diseases. The myasthenia/myositis/myocarditis overlap syndrome deserves special attention as it carries the highest risk of mortality. The role of neurotoxic pretreatment regimens, preexisting subclinical neurological autoimmune diseases and the risk of ICI-re-challenge after irNAEs has to be further investigated.
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Affiliation(s)
- Thomas Hundsberger
- Department of Neurology
- Department of Medical Oncology and Haematology, Cantonal Hospital, St. Gallen
| | - Bettina Schreiner
- Department of Neurology, University of Zurich, University Hospital of Zurich, Switzerland
| | - Patrick Roth
- Department of Neurology, University of Zurich, University Hospital of Zurich, Switzerland
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Cuenca JA, Hanmandlu A, Wegner R, Botdorf J, Tummala S, Iliescu CA, Nates JL, Reddy DR. Management of respiratory failure in immune checkpoint inhibitors-induced overlap syndrome: a case series and review of the literature. BMC Anesthesiol 2023; 23:310. [PMID: 37700240 PMCID: PMC10496364 DOI: 10.1186/s12871-023-02257-z] [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: 11/09/2022] [Accepted: 08/24/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Checkpoint inhibitor-induced overlap syndrome ([OS] myocarditis, and myositis with or without myasthenia gravis) is rare but life-threatening. CASES PRESENTATION Here we present a case series of four cancer patients that developed OS. High troponinemia raised the concern for myocarditis in all the cases. However, the predominant clinical feature differed among the cases. Two patients showed marked myocarditis with a shorter hospital stay. The other two patients had a prolonged ICU stay due to severe neuromuscular involvement secondary to myositis and myasthenia gravis. Treatment was based on steroids, plasmapheresis, intravenous immunoglobulin, and immunosuppressive biological agents. CONCLUSION The management of respiratory failure is challenging, particularly in those patients with predominant MG. Along with intensive clinical monitoring, bedside respiratory mechanics can guide the decision-making process of selecting a respiratory support method, the timing of elective intubation and extubation.
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Affiliation(s)
- John A Cuenca
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Ankit Hanmandlu
- McGovern School of Medicine, University of Texas, Houston, TX, USA
| | - Robert Wegner
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Joshua Botdorf
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Sudhakar Tummala
- Department of Neuro-oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cezar A Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph L Nates
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Dereddi R Reddy
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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Kosick TI, Patel K, Jasinski J, Dada B. A Case of Pembrolizumab-Induced Myasthenia Gravis. Cureus 2023; 15:e45455. [PMID: 37859893 PMCID: PMC10583611 DOI: 10.7759/cureus.45455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/21/2023] Open
Abstract
With the advent of new cancer treatments, immunotherapy has emerged as an increasingly promising strategy. Undoubtedly, it has pushed oncology into a new era and is providing patients with unprecedented results. As with many treatments, however, adverse effects lead to setbacks in progress. Pembrolizumab is an immunomodulating medication that functions by binding to programmed cell death protein 1 (PD-1) receptors of T cells thereby upregulating the immune system to more effectively detect and target cancer. Myasthenia gravis (MG) is a reported side effect of this medication. Our patient is an 87-year-old male with urothelial cell bladder cancer who developed MG following the administration of pembrolizumab and was treated with plasma exchange therapy. We aim to examine the existing literature concerning treatments for MG, with a particular focus on myasthenia gravis induced by pembrolizumab. We will discuss the occurrence rates and results of such instances, along with their implications for the future of these potential therapies.
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Affiliation(s)
- Thomas I Kosick
- Internal Medicine, St. Luke's University Health Network, Easton, USA
| | - Krima Patel
- Neurology, St. Luke's University Health Network, Easton, USA
| | - Jacob Jasinski
- Internal Medicine, St. Luke's University Health Network, Easton, USA
| | - Bolanle Dada
- Internal Medicine, St. Luke's University Health Network, Easton, USA
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Weaver JM, Dodd K, Knight T, Chaudhri M, Khera R, Lilleker JB, Roberts M, Lorigan P, Cooksley T. Improved outcomes with early immunosuppression in patients with immune-checkpoint inhibitor induced myasthenia gravis, myocarditis and myositis: a case series. Support Care Cancer 2023; 31:518. [PMID: 37572133 DOI: 10.1007/s00520-023-07987-x] [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: 04/22/2023] [Accepted: 08/07/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE Myasthenia gravis (MG) is a rare but life-threatening complication of immune-checkpoint inhibitor (ICI) therapy and often co-presents with myositis and myocarditis. Previous case series of ICI-related MG have reported high mortality rates. We present a series of ten patients from a tertiary oncology centre outlining outcomes of an early multi-modal immunosuppression strategy. METHODS We reviewed The Christie Hospital database of immunotherapy-related toxicity from 2017 to 2020. Symptom severity was assessed using the Myasthenia Gravis Foundation of America (MGFA) classification. RESULTS Ten patients with ICI-related MG were identified. All patients presented following 1 (n = 4) or 2 (n = 6) cycles of ICI. Symptom progression was rapid with a median of 3 days from onset of symptoms to admission. Concomitant myositis and myocarditis were observed in nine patients. AChR or MuSK autoantibodies were positive in six patients. All patients received urgent treatment with intravenous methylprednisolone (IVMP) and eight received intravenous immunoglobulin (IVIG). A single patient died from myasthenia-related symptoms; the remaining 9 patients were successfully discharged. CONCLUSION In our cohort, we demonstrate good outcomes associated with early intensive immunosuppressive treatment with IVIG and IVMP. An agreed national treatment protocol or clinical discussion forum would be beneficial.
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Affiliation(s)
- Jamie Mj Weaver
- Department of Acute Medicine, The Christie NHS Foundation Trust, Wilmslow Road Manchester, Manchester, UK
- University of Manchester, Manchester, UK
| | - Katie Dodd
- Manchester centre for Clinical Neurosciences, Northern Care Alliance, Manchester, UK
| | - Tom Knight
- Department of Acute Medicine, The Christie NHS Foundation Trust, Wilmslow Road Manchester, Manchester, UK
| | | | - Raj Khera
- Department of Acute Medicine, The Christie NHS Foundation Trust, Wilmslow Road Manchester, Manchester, UK
| | - James B Lilleker
- Manchester centre for Clinical Neurosciences, Northern Care Alliance, Manchester, UK
| | - Mark Roberts
- Manchester centre for Clinical Neurosciences, Northern Care Alliance, Manchester, UK
| | - Paul Lorigan
- Department of Acute Medicine, The Christie NHS Foundation Trust, Wilmslow Road Manchester, Manchester, UK
- University of Manchester, Manchester, UK
| | - Tim Cooksley
- Department of Acute Medicine, The Christie NHS Foundation Trust, Wilmslow Road Manchester, Manchester, UK.
- University of Manchester, Manchester, UK.
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Curkovic NB, Johnson DB. Updates in toxicities associated with immune checkpoint inhibitors. Expert Rev Clin Immunol 2023; 19:1117-1129. [PMID: 37276071 PMCID: PMC10527235 DOI: 10.1080/1744666x.2023.2221434] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/31/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have become a pillar of treatment for numerous cancers with increasing use in combination with other ICIs and in earlier stages of disease treatment. Although effective, ICI use is accompanied by a milieu of potentially bothersome or even life-threatening toxicities known as immune-related adverse events (irAEs), necessitating careful monitoring and early intervention. AREAS COVERED In this review, we provide an overview of recent advances surrounding toxicity pathophysiology and treatment in the context of relevant organ systems. An emphasis on current treatments by toxicity, as well as updates on steroid-refractory toxicities, chronic toxicities, and biomarkers will be a focus of this update on the current understanding of irAEs. EXPERT OPINION ICI toxicities are a major limitation on the deployment of multi-agent ICI regimens and are thus a major priority to understand, treat, and prevent. Recent developments have led to greater understanding of the pathophysiology of these events, which may lead to improved prevention or mitigation strategies. Further, early studies have also suggested steroid-sparing approaches that may be useful. Ultimately, preventing and managing irAEs will be a key goal toward successful ICI treatment across a broader range of patients with cancer.
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Affiliation(s)
| | - Douglas B. Johnson
- Department of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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Yamanaka T, Takemura K, Hayashida M, Suyama K, Urakami S, Miura Y. Cabozantinib-induced serum creatine kinase elevation and rhabdomyolysis: a retrospective case series. Cancer Chemother Pharmacol 2023:10.1007/s00280-023-04557-0. [PMID: 37380798 DOI: 10.1007/s00280-023-04557-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/13/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE Rhabdomyolysis, which is primarily characterized by serum creatine kinase (CK) elevation, is a potentially fatal disease, and it can occur in a variety of etiologies, including drug-induced. Cabozantinib is one of the standard treatments for patients with renal cell carcinoma (RCC). This retrospective case series aimed to investigate the frequency of cabozantinib-induced CK elevation and rhabdomyolysis, and to reveal their detailed clinical features. METHODS To investigate the frequency of cabozantinib-induced serum CK elevation and rhabdomyolysis, we retrospectively reviewed the clinical information and laboratory data of the patients with advanced RCC who received cabozantinib monotherapy at our institution from April 2020 to April 2023. Data were retrieved from the electronic medical records and the RCC database of our institution. Primary endpoint of the current case series was the frequency of CK elevation and rhabdomyolysis. RESULTS Sixteen patients were retrieved form the database and 13 were included in the case series (excluded by clinical trial enrollment [n = 2] and short-term administration [n = 1]). Eight (61.5%) patients among them experienced serum CK elevation, including five patients who were classified into grade 1. CK elevation occurred a median of 14 days after initiation of cabozantinib. Two patients with grade 2 or 3 of CK elevation developed rhabdomyolysis with muscle weakness and/or acute kidney injury. CONCLUSIONS CK elevation may frequently happen during cabozantinib treatment, and in most cases, it may be asymptomatic and may not be clinically problematic. However, medical providers should be aware that symptomatic CK elevations suggestive of rhabdomyolysis may occasionally occur.
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Affiliation(s)
- Taro Yamanaka
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | - Kohji Takemura
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | | | - Koichi Suyama
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | | | - Yuji Miura
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan.
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41
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Alsalem AN, Scarffe LA, Briemberg HR, Aaroe AE, Harrison RA. Neurologic Complications of Cancer Immunotherapy. Curr Oncol 2023; 30:5876-5897. [PMID: 37366923 DOI: 10.3390/curroncol30060440] [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: 05/05/2023] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Immunotherapy has revolutionized cancer treatment over the past decade. As it is increasingly introduced into routine clinical practice, immune-related complications have become more frequent. Accurate diagnosis and treatment are essential, with the goal of reduced patient morbidity. This review aims to discuss the various clinical manifestations, diagnosis, treatments, and prognosis of neurologic complications associated with the use of immune checkpoint inhibitors, adoptive T-cell therapies, and T-cell redirecting therapies. We also outline a suggested clinical approach related to the clinical use of these agents.
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Affiliation(s)
- Aseel N Alsalem
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Leslie A Scarffe
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Hannah R Briemberg
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Ashley E Aaroe
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Rebecca A Harrison
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
- Division of Medical Oncology, BC Cancer, University of British Columbia, Vancouver, BC V5Z 4E6, Canada
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42
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Eglenen Polat B, Safi D, Hafez M, Kamran A. Pembrolizumab-Induced Myasthenia Gravis: A Case Report and Review of the Literature. Cureus 2023; 15:e41087. [PMID: 37519591 PMCID: PMC10378713 DOI: 10.7759/cureus.41087] [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: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Myasthenia gravis (MG) is one of the most common neuromuscular adverse effects of immune checkpoint inhibitors (ICIs) and can result in significant morbidity and mortality when it affects the bulbar and respiratory muscles. Diagnosing immune-related MG (irMG) is challenging due to its nonspecific presentation and high negativity rate for MG antibody markers. Patients, primary care providers, and emergency care providers should be educated about MG as a potential adverse effect of ICIs for timely diagnosis and intervention.
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Affiliation(s)
- Buse Eglenen Polat
- Internal Medicine, West Virginia University (WVU) Medicine Camden Clark Medical Center, Parkersburg, USA
| | - Danish Safi
- Hematology and Medical Oncology, West Virginia University School of Medicine, Morgantown, USA
| | - Maria Hafez
- Hematology and Medical Oncology, West Virginia University School of Medicine, Morgantown, USA
| | - Amir Kamran
- Hematology and Medical Oncology, Charleston Area Medical Center, Charleston, USA
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Fa'ak F, Buni M, Falohun A, Lu H, Song J, Johnson DH, Zobniw CM, Trinh VA, Awiwi MO, Tahon NH, Elsayes KM, Ludford K, Montazari EJ, Chernis J, Dimitrova M, Sandigursky S, Sparks JA, Abu-Shawer O, Rahma O, Thanarajasingam U, Zeman AM, Talukder R, Singh N, Chung SH, Grivas P, Daher M, Abudayyeh A, Osman I, Weber J, Tayar JH, Suarez-Almazor ME, Abdel-Wahab N, Diab A. Selective immune suppression using interleukin-6 receptor inhibitors for management of immune-related adverse events. J Immunother Cancer 2023; 11:e006814. [PMID: 37328287 PMCID: PMC10277540 DOI: 10.1136/jitc-2023-006814] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Management of immune-related adverse events (irAEs) is important as they cause treatment interruption or discontinuation, more often seen with combination immune checkpoint inhibitor (ICI) therapy. Here, we retrospectively evaluated the safety and effectiveness of anti-interleukin-6 receptor (anti-IL-6R) as therapy for irAEs. METHODS We performed a retrospective multicenter study evaluating patients diagnosed with de novo irAEs or flare of pre-existing autoimmune disease following ICI and were treated with anti-IL-6R. Our objectives were to assess the improvement of irAEs as well as the overall tumor response rate (ORR) before and after anti-IL-6R treatment. RESULTS We identified a total of 92 patients who received therapeutic anti-IL-6R antibodies (tocilizumab or sarilumab). Median age was 61 years, 63% were men, 69% received anti-programmed cell death protein-1 (PD-1) antibodies alone, and 26% patients were treated with the combination of anti-cytotoxic T lymphocyte antigen-4 and anti-PD-1 antibodies. Cancer types were primarily melanoma (46%), genitourinary cancer (35%), and lung cancer (8%). Indications for using anti-IL-6R antibodies included inflammatory arthritis (73%), hepatitis/cholangitis (7%), myositis/myocarditis/myasthenia gravis (5%), polymyalgia rheumatica (4%), and one patient each with autoimmune scleroderma, nephritis, colitis, pneumonitis and central nervous system vasculitis. Notably, 88% of patients had received corticosteroids, and 36% received other disease-modifying antirheumatic drugs (DMARDs) as first-line therapies, but without adequate improvement. After initiation of anti-IL-6R (as first-line or post-corticosteroids and DMARDs), 73% of patients showed resolution or change to ≤grade 1 of irAEs after a median of 2.0 months from initiation of anti-IL-6R therapy. Six patients (7%) stopped anti-IL-6R due to adverse events. Of 70 evaluable patients by RECIST (Response Evaluation Criteria in Solid Tumors) V.1.1 criteria; the ORR was 66% prior versus 66% after anti-IL-6R (95% CI, 54% to 77%), with 8% higher complete response rate. Of 34 evaluable patients with melanoma, the ORR was 56% prior and increased to 68% after anti-IL-6R (p=0.04). CONCLUSION Targeting IL-6R could be an effective approach to treat several irAE types without hindering antitumor immunity. This study supports ongoing clinical trials evaluating the safety and efficacy of tocilizumab (anti-IL-6R antibody) in combination with ICIs (NCT04940299, NCT03999749).
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Affiliation(s)
- Faisal Fa'ak
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Maryam Buni
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adewunmi Falohun
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Huifang Lu
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juhee Song
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Van A Trinh
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Khaled M Elsayes
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kaysia Ludford
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Emma J Montazari
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julia Chernis
- University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - Maya Dimitrova
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Sabina Sandigursky
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Jeffrey A Sparks
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Osama Abu-Shawer
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Osama Rahma
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Rafee Talukder
- Fred Hutchinson Cancer Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Namrata Singh
- Fred Hutchinson Cancer Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sarah H Chung
- Fred Hutchinson Cancer Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Petros Grivas
- Fred Hutchinson Cancer Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - May Daher
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ala Abudayyeh
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Iman Osman
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Jeffrey Weber
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Jean H Tayar
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Noha Abdel-Wahab
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Assiut University Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Adi Diab
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Chen YC, Jaffer M, Zhou L, Moslehi J, Forsyth PA, Fecher LA. A Brain, A Heart, and the Courage: Balancing Benefit and Toxicity of Immunotherapy in Melanoma. Am Soc Clin Oncol Educ Book 2023; 43:e390594. [PMID: 37229626 DOI: 10.1200/edbk_390594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The overall survival of advanced melanoma has improved dramatically. Immunotherapies, specifically checkpoint inhibitors, have played a large role in this improvement. These agents have also shown benefit in the adjuvant setting, are approved for treatment of resected stage II, III, and IV melanoma, and play an evolving role in the neoadjuvant setting. Although generally well tolerated, immune-related adverse events occur and can be severe. Here we focus on some severe and potentially long term toxicities, including cardiovascular and neurologic toxicities. Our understanding of the acute and long-term toxicities of immune checkpoint inhibitors continues to evolve. Oncologists must continue to balance cancer risk and treatment-related toxicities.
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Affiliation(s)
- Yen-Chou Chen
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
- Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Muhammad Jaffer
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
| | - Lylybell Zhou
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Javid Moslehi
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Peter A Forsyth
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
- Department of Oncology, Moffitt Cancer Center and University of South Florida, Tampa, FL
| | - Leslie A Fecher
- Rogel Cancer Center at the University of Michigan, Ann Arbor, MI
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45
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Masi G, Pham MC, Karatz T, Oh S, Payne AS, Nowak RJ, Howard JF, Guptill JT, Juel VC, O'Connor KC. Clinicoserological insights into patients with immune checkpoint inhibitor-induced myasthenia gravis. Ann Clin Transl Neurol 2023; 10:825-831. [PMID: 36924454 PMCID: PMC10187728 DOI: 10.1002/acn3.51761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
To compare the immunopathology of immune checkpoint inhibitor-induced myasthenia gravis (ICI-MG) and idiopathic MG, we profiled the respective AChR autoantibody pathogenic properties. Of three ICI-MG patients with AChR autoantibodies, only one showed complement activation and modulation/blocking potency, resembling idiopathic MG. In contrast, AChR autoantibody-mediated effector functions were not detected in the other two patients, questioning the role of their AChR autoantibodies as key mediators of pathology. The contrasting properties of AChR autoantibodies in these cases challenge the accuracy of serological testing in establishing definite ICI-MG diagnoses and underscore the importance of a thorough clinical assessment when evaluating ICI-related adverse events.
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Affiliation(s)
- Gianvito Masi
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - Minh C Pham
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - Tabitha Karatz
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Sangwook Oh
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
| | - Aimee S Payne
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - James F Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, CB#7025, Houpt Building, 170 Manning Drive, Chapel Hill, North Carolina, 27599-7025, USA
| | - Jeffrey T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Vern C Juel
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Kevin C O'Connor
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
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McKevitt FM. What neurologists can do for neuro-oncology patients. Pract Neurol 2023:pn-2022-003665. [PMID: 37019612 DOI: 10.1136/pn-2022-003665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 04/07/2023]
Abstract
Neuro-oncology is a branch of medical science concerned with managing central nervous system tumours and neurological complications of cancer. Patients with brain tumours need a multidisciplinary approach to their care and neurologists can play a key part within that team. This review shows how neurologists can contribute to the care of patients with neuro-oncological disease at various points during the illness, including at initial diagnosis, during symptom management and at end of life assisting with palliative seizure management. The review focuses on brain tumour-related epilepsy, the complications of brain tumour treatments and the neurological complications of systemic cancer treatments including immunotherapies.
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Affiliation(s)
- Fiona M McKevitt
- Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Niimura T, Zamami Y, Miyata K, Mikami T, Asada M, Fukushima K, Yoshino M, Mitsuboshi S, Okada N, Hamano H, Sakurada T, Matsuoka-Ando R, Aizawa F, Yagi K, Goda M, Chuma M, Koyama T, Izawa-Ishizawa Y, Yanagawa H, Fujino H, Yamanishi Y, Ishizawa K. Characterization of Immune Checkpoint Inhibitor-Induced Myasthenia Gravis Using the US Food and Drug Administration Adverse Event Reporting System. J Clin Pharmacol 2023; 63:473-479. [PMID: 36453166 DOI: 10.1002/jcph.2187] [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: 09/02/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022]
Abstract
Myasthenia gravis (MG) is a rare but fatal adverse event of immune checkpoint inhibitors (ICIs). We assessed whether patient characteristics differed between those with ICI-related myasthenia gravis and those with idiopathic myasthenia gravis. Reports from the US Food and Drug Administration Adverse Event Reporting System were analyzed. Multivariate analyses were conducted to evaluate the associations between age, sex, and ICI treatment and the reporting rate of myasthenia gravis. Among 5 464 099 cases between 2011 and 2019, 53 447 were treated with ICIs. Myasthenia gravis was reported more often in ICI users. Multiple logistic regression analyses showed that the reporting rate of ICI-related myasthenia gravis did not differ significantly between men and women; however, it was higher in older people than in younger people (adjusted odds ratio, 2.4 [95%CI, 1.84-3.13]). We also investigated useful signs for the early detection of myositis and myocarditis, which are fatal when overlapping with ICI-related myasthenia gravis. Patients with elevated serum creatine kinase or troponin levels were more likely to have concurrent myositis and myocarditis. Unlike idiopathic myasthenia gravis, there was no sex difference in the development of ICI-related myasthenia gravis, which may be more common in older people. Considering the physiological muscle weakness that occurs in the elderly, it may be necessary to monitor ICI-related myasthenia gravis more closely in older people.
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Affiliation(s)
- Takahiro Niimura
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Yoshito Zamami
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Koji Miyata
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Takahisa Mikami
- Department of Neurology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mizuho Asada
- Department of Pharmacy, Tokyo Medical and Dental University Hospital, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Medical Molecular Informatics, Meiji Pharmaceutical University, Tokyo, Japan
| | - Keijo Fukushima
- Department of Pharmacology for Life Sciences, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Masaki Yoshino
- Department of Pharmacy, Niigata Prefectural Cancer Center Hospital, Niigata, Japan
| | | | - Naoto Okada
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Hirofumi Hamano
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Takumi Sakurada
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Rie Matsuoka-Ando
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Fuka Aizawa
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Kenta Yagi
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Mitsuhiro Goda
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Masayuki Chuma
- Department of Hospital Pharmacy and Pharmacology, Asahikawa Medical University, Asahikawa, Japan
| | - Toshihiro Koyama
- Department of Health Data Science, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yuki Izawa-Ishizawa
- Department of Pharmacology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Hiroaki Yanagawa
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
- Faculty of Health and Welfare Department of Nursing, Tokushima Bunri University, Tokushima, Japan
| | - Hiromichi Fujino
- Department of Pharmacology for Life Sciences, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yoshihiro Yamanishi
- Department of Bioscience and Bioinformatics, Faculty of Computer Science and Systems Engineering, Kyushu Institute of Technology, Fukuoka, Japan
| | - Keisuke Ishizawa
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
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Wang C, Zeng H, Fang W, Song L. Clinical characteristics, treatment and outcome of nivolumab-induced myasthenia gravis. Invest New Drugs 2023; 41:333-339. [PMID: 36988830 DOI: 10.1007/s10637-023-01347-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/27/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND To investigate the clinical features of nivolumab-induced myasthenia gravis (MG) and provide evidence for the rational use of nivolumab in the clinic. METHODS We collected case reports and case series of nivolumab-induced MG for retrospective analysis by searching Chinese and English databases from 2014 to October 31, 2022. RESULTS Of the 67 patients included, the median age was 72.5 years (range 34-86), including 44 males (65.7%). MG occurred in the median 2nd treatment cycle (range, 1st-6th) after nivolumab treatment, being mild in 12 patients (17.9%) and moderate to severe in 44 patients (65.7%). Ptosis (n = 48,71.6%), diplopia (n = 34,50.7%), dyspnea (n = 30, 44.8%), limb muscle weakness (n = 30, 44.8%) and dysphagia (n = 27, 40.3%) were the most common symptoms. Fifty-six patients (83.6%) were classified as having generalized myasthenia gravis (GMG), the remaining 11 patients (16.4%) isolated ocular myasthenia gravis (OMG). Twenty-one patients (31.3%) had MG combined with myositis, 10 patients (14.9%) had myocarditis, and 9 patients (13.4%) had both myositis and myocarditis. Forty patients (59.7%) were positive for anti-acetylcholine receptor antibodies. The serum creatine kinase level was significantly increased in 37 patients (55.2%), with a median value of 4000 IU/L (219,14229). After discontinuation of nivolumab and immunosuppressive therapy, 46 patients (68.7%) finally recovered or improved their MG symptoms, while 15 patients (22.4%) did not recover. Eleven patients (16.4%) died of MG complications. CONCLUSION MG is a serious and rare adverse reaction to nivolumab. Nivolumab-induced MG should be timely and correctly identified, and immunotherapy should be given.
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Affiliation(s)
- Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China
| | - Hanqing Zeng
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China
| | - Liying Song
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China.
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Zhao S, Zhou Y, Sun W, Li Z, Wang C. Clinical features, diagnosis, and management of pembrolizumab-induced myasthenia gravis. Clin Exp Immunol 2023; 211:85-92. [PMID: 36426591 PMCID: PMC10019122 DOI: 10.1093/cei/uxac108] [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: 09/15/2022] [Revised: 10/26/2022] [Accepted: 11/19/2022] [Indexed: 11/26/2022] Open
Abstract
Myasthenia gravis (MG) is a rare but life-threatening adverse event with pembrolizumab. What is known about pembrolizumab-induced MG is largely based on case reports. This analysis collected pembrolizumab-induced MG cases from Chinese and English databases published from September 1, 2014, to June 30, 2022. Demographic and clinical information of the patients, management, and outcome data were collected and analyzed. Sixty-five patients with a median age of 73 years (range 30-86), including 43 male patients (66.2%), were included. Eight patients (12.3%) with prior MG experienced worsening symptoms after receiving pembrolizumab. The median time to the onset of MG was four weeks (range 0.7-27). The most common symptoms were ptosis (81.5%, 53 patients), diplopia (50.8%, 33 patients), dyspnea (44.6%, 29 patients), trunk or peripheral weakness (43.1%, 28 patients), and dysphagia (30.8%, 20 patients). Concurrent myositis and myocarditis occurred in 13 (20.0%) and 17 patients (26.2%). Pembrolizumab was discontinued in 63 patients (96.9%). Forty-four patients (67.7%) received combination therapies based on steroids (intravenous immune globulin, plasmapheresis, or immunosuppressants). Twenty-seven patients (41.5%) had symptoms completely recovered. Fourteen patients (21.5%) died from immunotoxicity or primary cancers. Clinicians should consider the possibility of pembrolizumab-induced MG, especially during the first eight weeks of therapy. Patients should be treated as early as possible, regardless of the severity of the initial symptoms.
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Affiliation(s)
- Shaoli Zhao
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, China
| | - Yulu Zhou
- Department of Pharmacy, Hunan Provincial Maternal and Child Health Care, Hospital Changsha, 410028 Hunan, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, China
| | - Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, China
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50
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Farina A, Villagrán-García M, Honnorat J. Neurological adverse events of immune checkpoint inhibitors: An update of clinical presentations, diagnosis, and management. Rev Neurol (Paris) 2023; 179:506-515. [PMID: 36934022 DOI: 10.1016/j.neurol.2023.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023]
Abstract
The use of immune checkpoint inhibitors (ICIs) has represented a major advance in cancer treatment. By enhancing endogenous immune responses to destroy cancer cells, ICIs can cause immune-related adverse events (irAEs), with possible involvement of any organ system. IrAEs are frequent, particularly those involving the skin or the endocrine system, and usually completely reversible after temporary immunosuppression, while neurological irAEs (n-irAEs) are relatively rare, often severe, and they carry a considerable risk of mortality and long-term disability. They usually affect the peripheral nervous system, mainly manifesting as myositis, polyradiculoneuropathy, or cranial neuropathy, and, less frequently, involve the central nervous system, causing encephalitis, meningitis, or myelitis. Although somehow reminiscent of the disorders that neurologists are familiar to deal with in their daily practice, n-irAEs are characterized by distinctive features from their idiopathic counterparts; for instance, myositis may have a predominant oculo-bulbar involvement reminiscent of myasthenia gravis and frequently associates with myocarditis; peripheral neuropathy, although often resembling Guillain-Barré syndrome, usually responds to corticosteroids. Remarkably, several associations between the neurological phenotype and the type of ICIs or the type of cancer have emerged in the last few years, and the growing administration of ICIs in patients with neuroendocrine cancers has led to an increased number of reports of paraneoplastic neurological syndromes (triggered or worsened by ICIs). This review aims to update current knowledge regarding the clinical presentation of n-irAEs. We also discuss the essential parts of the diagnostic approach, and we provide general recommendations for the management of these disorders.
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Affiliation(s)
- A Farina
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino, Università di Firenze, Firenze, Italy
| | - M Villagrán-García
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France
| | - J Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France.
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