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Goodman RS, Johnson DB, Balko JM. Corticosteroids and Cancer Immunotherapy. Clin Cancer Res 2023; 29:2580-2587. [PMID: 36648402 PMCID: PMC10349688 DOI: 10.1158/1078-0432.ccr-22-3181] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/22/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023]
Abstract
Despite revolutionizing cancer management, immunotherapies dysregulate the immune system, leading to immune-mediated adverse events. These common and potentially dangerous toxicities are often treated with corticosteroids, which are among the most prescribed drugs in oncology for a wide range of cancer and noncancer indications. While steroids exert several mechanisms to reduce immune activity, immunotherapies, such as immune checkpoint inhibitors (ICI), are designed to enhance the immune system's inherent antitumor activity. Because ICI requires an intact and robust immune response, the immunosuppressive properties of steroids have led to a widespread concern that they may interfere with antitumor responses. However, the existing data of the effect of systemic steroids on immunotherapy efficacy remain somewhat conflicted and unclear. To inform clinical decision-making and improve outcomes, we review the impact of steroids on antitumor immunity, recent advances in the knowledge of their impact on ICI efficacy in unique populations and settings, associated precautions, and steroid-sparing treatment approaches.
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Affiliation(s)
| | - Douglas B. Johnson
- Department of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Justin M. Balko
- Department of Medicine, Department of Cancer Biology, Vanderbilt University Medical Center, Nashville, Tennessee
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Rao Ullur A, Côté G, Pelletier K, Kitchlu A. Immunotherapy in oncology and the kidneys: a clinical review of the evaluation and management of kidney immune-related adverse events. Clin Kidney J 2023; 16:939-951. [PMID: 37261008 PMCID: PMC10229281 DOI: 10.1093/ckj/sfad014] [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: 09/22/2022] [Indexed: 11/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICI) are now widely used in the treatment of many cancers, and currently represent the standard of care for multiple malignancies. These agents enhance the T cell immune response to target cancer tissues, and have demonstrated considerable benefits for cancer outcomes. However, despite these improved outcomes, there are important kidney immune-related adverse events (iRAEs) associated with ICI. Acute tubulo-interstitial nephritis remains the most frequent kidney iRAE, however glomerular lesions and electrolytes disturbances are increasingly being recognized and reported. In this review, we summarize clinical features and identify risk factors for kidney iRAEs, and discuss the current understanding of pathophysiologic mechanisms. We highlight the evidence basis for guideline-recommended management of ICI-related kidney injury as well as gaps in current knowledge. We advocate for judicious use of kidney biopsy to identify ICI-associated kidney injury, and early use of corticosteroid treatment where appropriate. Selected patients may also be candidates for re-challenge with ICI therapy after a kidney iRAE, in view of current data on recurrent rates of kidney injury. Risk of benefits of re-challenge must be considered on an individual considering patient preferences and prognosis. Lastly, we review current knowledge of ICI use in the setting of patients with end-stage kidney disease, including kidney transplant recipients and those receiving dialysis, which suggest that these patients should not be summarily excluded from the potential benefits of these cancer therapies.
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Affiliation(s)
- Avinash Rao Ullur
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Gabrielle Côté
- Division of Nephrology, Department of Medicine, CHU de Québec, Université Laval, Quebec City, Canada
| | - Karyne Pelletier
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
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3
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Lowes K, Reinecke J, Brunner M, Scholz M, Kitz J, Michels B, Mekolli A, Gaedcke J, Seif Amir Hosseini A, Ströbel P, Ghadimi M, Ellenrieder V, Koenig A, Koenig U. Effectiveness of fourth-line dual immunotherapy in hepatocellular carcinoma with simultaneous steroid administration for immune-related hepatitis. Therap Adv Gastroenterol 2022; 15:17562848211051026. [PMID: 35178123 PMCID: PMC8844730 DOI: 10.1177/17562848211051026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 08/12/2021] [Indexed: 02/04/2023] Open
Abstract
Medical therapy of advanced hepatocellular carcinoma (HCC) remains an emerging subject, but therapeutic sequences together with toxicity management are rarely described. Herein, we report the case of a therapeutic sequence and toxicity management in a 72-year old White male with advanced non-cirrhotic HCC. The HCC of this patient was refractory against treatment with several tyrosine kinase inhibitors, including lenvatinib and cabozantinib or immune combination of pembrolizumab and lenvatinib. Double immune combination of nivolumab and ipilimumab was effective in fourth-line treatment but resulted in immunotherapy-related grade 4 hepatitis. This toxicity responded well to high doses of corticosteroids, and reinduction of dual immune combination remained effective despite continuation of high-dose corticosteroids in a non-cirrhotic HCC. This case demonstrated the efficacy of double immune therapy in higher treatment lines in advanced non-cirrhotic HCC even if the patient was treated with other immune modulatory therapies earlier. Moreover, it can remain effective under concomitant administration of high-dose corticosteroids.
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Affiliation(s)
- Kristina Lowes
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany
| | - Johanna Reinecke
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany
| | - Marius Brunner
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany
| | - Matthias Scholz
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Julia Kitz
- Department of Pathology, University Medical Center Goettingen, Goettingen, Germany
| | - Beate Michels
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany
| | - Ardian Mekolli
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany
| | - Jochen Gaedcke
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Philipp Ströbel
- Department of Pathology, University Medical Center Goettingen, Goettingen, Germany
| | - Michael Ghadimi
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany
| | | | - Ute Koenig
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany
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Aldea M, Orillard E, Mansi L, Marabelle A, Scotte F, Lambotte O, Michot JM. How to manage patients with corticosteroids in oncology in the era of immunotherapy? Eur J Cancer 2020; 141:239-251. [DOI: 10.1016/j.ejca.2020.09.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/15/2020] [Accepted: 09/25/2020] [Indexed: 02/08/2023]
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Gupta S, Cortazar FB, Riella LV, Leaf DE. Immune Checkpoint Inhibitor Nephrotoxicity: Update 2020. KIDNEY360 2020; 1:130-140. [PMID: 35372904 PMCID: PMC8809100 DOI: 10.34067/kid.0000852019] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Immune checkpoint inhibitors (ICPIs) have transformed the landscape of oncology, but are associated with a variety of autoimmune adverse events, including AKI. ICPI-associated AKI (ICPI-AKI) is emerging as an increasingly frequent cause of AKI in patients with cancer, and poses unique diagnostic and management challenges to clinicians who care for these patients. In this review, we describe the incidence and risk factors for ICPI-AKI, including proton pump inhibitor use, CKD, and combination immunotherapy. We discuss the limitations of the various definitions used for ICPI-AKI in prior studies, and propose a novel classification system (definite, probable, and possible ICPI-AKI) that recognizes the diagnostic uncertainty inherent in many cases. We discuss the key clinicopathologic features and treatment strategies for ICPI-AKI, including the role of kidney biopsy versus empirical treatment with steroids. We also explore the under-studied area of ICPI use in the setting of solid organ transplantation, where nephrologists and oncologists must balance the risk of rejection versus treating the underlying malignancy. Finally, we summarize existing data on the role of ICPI rechallenge after an episode of ICPI-AKI.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Frank B. Cortazar
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York; and
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Leonardo V. Riella
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Abstract
PURPOSE OF REVIEW This review addresses our current knowledge of immune-mediated colitis (IMC) and offers a practical guide to its management. RECENT FINDINGS Due to the similarity in clinical, endoscopic, and histologic findings between IMC and inflammatory bowel disease (IBD), gastroenterologists have tailored their approach to IMC management to that of IBD. Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that augment the T-cell anti-tumor response of the immune system and have demonstrated their importance in the treatment of a wide range of malignancies. With the growing benefits of ICIs, there are immune-related adverse events (irAEs) that mirror many known autoimmune diseases. Diarrhea and IMC are the most common and severe irAEs noted. No standardized guidelines exist in the management of these irAEs.
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Affiliation(s)
- Tara Menon
- The Ohio State University Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Anita Afzali
- The Ohio State University Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Aston WJ, Hope DE, Cook AM, Boon L, Dick I, Nowak AK, Lake RA, Lesterhuis WJ. Dexamethasone differentially depletes tumour and peripheral blood lymphocytes and can impact the efficacy of chemotherapy/checkpoint blockade combination treatment. Oncoimmunology 2019; 8:e1641390. [PMID: 31646089 PMCID: PMC6791454 DOI: 10.1080/2162402x.2019.1641390] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022] Open
Abstract
Dexamethasone is a synthetic glucocorticoid commonly used for the prevention and management of side effects in cancer patients undergoing chemotherapy. While it is effective as an anti-emetic and in preventing hypersensitivity reactions, dexamethasone depletes peripheral blood lymphocytes and impacts immune responses. The effect of dexamethasone on the number and quality of tumour-infiltrating leukocytes has not been reported. To address this, we calibrated the dose in two different strains of mice to achieve the same extent of peripheral blood lymphocyte depletion observed in patients with cancer. Doses that caused analogous depletion of T and B lymphocytes and NK cells from the peripheral blood, elicited no change in these populations within the tumour. The expression of immune checkpoint molecules PD-1, OX40, GITR and TIM3 on tumour-infiltrating lymphocytes was not altered. We found that dexamethasone had a small but significant deleterious impact on weakly efficacious chemoimmunotherapy but had no effect when the protocol was highly efficacious. Based on these results, we predict that dexamethasone will have a modest negative influence on the overall effectiveness of chemoimmunotherapy treatment.
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Affiliation(s)
- Wayne J. Aston
- National Centre for Asbestos Related Diseases, The University of Western Australia, Nedlands, WA, Australia
- Medical School, The University of Western Australia, Nedlands, WA, Australia
| | - Danika E. Hope
- National Centre for Asbestos Related Diseases, The University of Western Australia, Nedlands, WA, Australia
- School of Biomedical Sciences, The University of Western Australia, Nedlands, WA, Australia
| | - Alistair M. Cook
- National Centre for Asbestos Related Diseases, The University of Western Australia, Nedlands, WA, Australia
- Medical School, The University of Western Australia, Nedlands, WA, Australia
| | | | - Ian Dick
- National Centre for Asbestos Related Diseases, The University of Western Australia, Nedlands, WA, Australia
- School of Biomedical Sciences, The University of Western Australia, Nedlands, WA, Australia
| | - Anna K. Nowak
- National Centre for Asbestos Related Diseases, The University of Western Australia, Nedlands, WA, Australia
- Medical School, The University of Western Australia, Nedlands, WA, Australia
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Richard A. Lake
- National Centre for Asbestos Related Diseases, The University of Western Australia, Nedlands, WA, Australia
- School of Biomedical Sciences, The University of Western Australia, Nedlands, WA, Australia
| | - W. Joost Lesterhuis
- National Centre for Asbestos Related Diseases, The University of Western Australia, Nedlands, WA, Australia
- School of Biomedical Sciences, The University of Western Australia, Nedlands, WA, Australia
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Li H, Verma V, Brooks ED, Feng L, Zhang T, Welsh JW, Lin SH, Gomez D, Gandhi S, Heymach JV, Chang JY. Impact of Corticosteroid Administration on Outcomes Following Stereotactic Ablative Radiotherapy for Non-small-cell Lung Cancer. Clin Lung Cancer 2019; 20:e480-e488. [PMID: 31078421 DOI: 10.1016/j.cllc.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/27/2019] [Accepted: 03/03/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Radiotherapy produces immune-promoting effects, which may be blunted by the delivery of corticosteroids (CS). We thus aimed to evaluate the impact of CS use on recurrence and survival outcomes of patients with early stage non-small-cell lung cancer treated with stereotactic ablative radiotherapy (SABR). MATERIALS AND METHODS A prospectively registered database of patients with stage I to II (T1-3N0M0) stage non-small-cell lung cancer treated with SABR from 2004 to 2015 was queried. Concurrent CS administration was defined as receipt of CS within 2 days of the SABR course. Statistics included Kaplan-Meier survival analysis, Cox proportional hazards modeling, and cumulative incidence analysis utilizing death as a competing risk. RESULTS Of 912 patients, 87 (9.5%) received CS with their SABR course. The most common agent was prednisone (64.4%). Indications for CS use were chronic obstructive pulmonary disease in 53 cases (60.9%), chemotherapy in 7 (8.0%), arthritis in 7 (8.0%), chronic pain in 4 (4.6%), transplant-related in 3 (3.4%), and "others" in 13 (14.9%; pneumonia, asthma, anemia, etc.). The median follow-up time was 59.3 months. Compared with patients who did not receive CS, receipt of CS was associated with poorer overall survival (P = .004). However, CS administration was not associated with worse time to progression (P = .766) or any recurrence when using death as a competing risk (local P = .119, regional P = .449, distant P = .847, and any recurrence P = .708). Toxicity rates were not statistically different between cohorts. CONCLUSIONS These data do not suggest increased recurrence rates when patients undergoing SABR are administered corticosteroids. However, owing to limitations of retrospective analyses, individualized judgment is still recommended.
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Affiliation(s)
- Hongqi Li
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX; Department of Radiation Oncology, Airforce General Hospital PLA, Beijing, China
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA
| | - Eric D Brooks
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Lei Feng
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Tiening Zhang
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - James W Welsh
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Steven H Lin
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Daniel Gomez
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Saumil Gandhi
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - John V Heymach
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX.
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Kolb NA, Trevino CR, Waheed W, Sobhani F, Landry KK, Thomas AA, Hehir M. Neuromuscular complications of immune checkpoint inhibitor therapy. Muscle Nerve 2018; 58:10-22. [PMID: 29342325 DOI: 10.1002/mus.26070] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 01/10/2018] [Accepted: 01/14/2018] [Indexed: 12/31/2022]
Abstract
Immune checkpoint inhibitor (ICPI) therapy unleashes the body's natural immune system to fight cancer. ICPIs improve overall cancer survival, however, the unbridling of the immune system may induce a variety of immune-related adverse events. Neuromuscular immune complications are rare but they can be severe. Myasthenia gravis and inflammatory neuropathy are the most common neuromuscular adverse events but a variety of others including inflammatory myopathy are reported. The pathophysiologic mechanism of these autoimmune disorders may differ from that of non-ICPI-related immune diseases. Accordingly, while the optimal treatment for ICPI-related neuromuscular disorders generally follows a traditional paradigm, there are important novel considerations in selecting appropriate immunosuppressive therapy. This review presents 2 new cases, a summary of neuromuscular ICPI complications, and an approach to the diagnosis and treatment of these disorders. Muscle Nerve, 2018.
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Affiliation(s)
- Noah A Kolb
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
| | | | - Waqar Waheed
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
| | - Fatemeh Sobhani
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
| | - Kara K Landry
- Department of Medicine, University of Vermont Medical Center, 1 South Prospect Street, MS 405AR2, Burlington, Vermont, 05401, USA
| | - Alissa A Thomas
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
| | - Mike Hehir
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
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Safety of treatment with nivolumab after ipilimumab-related meningoradiculitis and bilateral optic neuropathy. Eur J Cancer 2017; 83:28-31. [DOI: 10.1016/j.ejca.2017.05.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/18/2017] [Indexed: 01/10/2023]
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González-Rodríguez E, Rodríguez-Abreu D. Immune Checkpoint Inhibitors: Review and Management of Endocrine Adverse Events. Oncologist 2016; 21:804-16. [PMID: 27306911 PMCID: PMC4943391 DOI: 10.1634/theoncologist.2015-0509] [Citation(s) in RCA: 168] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 02/19/2016] [Indexed: 12/11/2022] Open
Abstract
UNLABELLED : In recent years, immune checkpoint inhibitors have emerged as effective therapies for advanced neoplasias. As new checkpoint target blockers become available and additional tumor locations tested, their use is expected to increase within a short time. Immune-related adverse events (irAEs) affecting the endocrine system are among the most frequent and complex toxicities. Some may be life-threatening if not recognized; hence, appropriate guidance for oncologists is needed. Despite their high incidence, endocrine irAEs have not been fully described for all immunotherapy agents available. This article is a narrative review of endocrinopathies associated with cytotoxic T lymphocyte-associated antigen-4, blockade of programmed death receptor 1 and its ligand inhibitors, and their combination. Thyroid dysfunction is the most frequent irAE reported, and hypophysitis is characteristic of ipilimumab. Incidence, timing patterns, and clinical presentation are discussed, and practical recommendations for clinical management are suggested. Heterogeneous terminology and lack of appropriate resolution criteria in clinical trials make adequate evaluation of endocrine AEs difficult. It is necessary to standardize definitions to contrast incidences and characterize toxicity patterns. To provide optimal care, a multidisciplinary team that includes endocrinology specialists is recommended. IMPLICATIONS FOR PRACTICE Immune checkpoint inhibitors are already part of oncologists' therapeutic arsenal as effective therapies for otherwise untreatable neoplasias, such as metastatic melanoma or lung cancer. Their use is expected to increase exponentially in the near future as additional agents become available and their approval is extended to different tumor types. Adverse events affecting the endocrine system are among the most frequent and complex toxicities oncologists may face, and some may be life-threatening if not recognized. This study reviews endocrinopathies associated to immune checkpoint inhibitors available to date. Incidence, timing patterns, and clinical presentation are discussed, and practical recommendations for management are proposed.
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Affiliation(s)
- Elisa González-Rodríguez
- Section of Endocrinology and Nutrition, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Delvys Rodríguez-Abreu
- Section of Medical Oncology, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Wilgenhof S, Corthals J, Heirman C, van Baren N, Lucas S, Kvistborg P, Thielemans K, Neyns B. Phase II Study of Autologous Monocyte-Derived mRNA Electroporated Dendritic Cells (TriMixDC-MEL) Plus Ipilimumab in Patients With Pretreated Advanced Melanoma. J Clin Oncol 2016; 34:1330-8. [DOI: 10.1200/jco.2015.63.4121] [Citation(s) in RCA: 207] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Autologous monocyte-derived dendritic cells (DCs) electroporated with synthetic mRNA (TriMixDC-MEL) are immunogenic and have antitumor activity as a monotherapy in patients with pretreated advanced melanoma. Ipilimumab, an immunoglobulin G1 monoclonal antibody directed against the cytotoxic T-lymphocyte-associated protein 4 receptor that counteracts physiologic suppression of T-cell function, improves the overall survival of patients with advanced melanoma. This phase II study investigated the combination of TriMixDC-MEL and ipilimumab in patients with pretreated advanced melanoma. Patients and Methods Thirty-nine patients were treated with TriMixDC-MEL (4 × 106 cells administered intradermally and 20 × 106 cells administered intravenously) plus ipilimumab (10 mg/kg every 3 weeks for a total of four administrations, followed by maintenance therapy every 12 weeks in patients who remained progression free). Six-month disease control rate according to the immune-related response criteria served as the primary end point. Results The 6-month disease control rate was 51% (95% CI, 36% to 67%), and the overall tumor response rate was 38% (including eight complete and seven partial responses). Seven complete responses and one partial tumor response are ongoing after a median follow-up time of 36 months (range, 22 to 43 months). The most common treatment-related adverse events (all grades) consisted of local DC injection site skin reactions (100%), transient post–DC infusion chills (38%) and flu-like symptoms (84%), dermatitis (64%), hepatitis (13%), hypophysitis (15%), and diarrhea/colitis (15%). Grade 3 or 4 immune-related adverse events occurred in 36% of patients. There was no grade 5 adverse event. Conclusion The combination of TriMixDC-MEL and ipilimumab is tolerable and results in an encouraging rate of highly durable tumor responses in patients with pretreated advanced melanoma.
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Affiliation(s)
- Sofie Wilgenhof
- Sofie Wilgenhof, Kris Thielemans, and Bart Neyns, Universitair Ziekenhuis Brussel; Sofie Wilgenhof, Jurgen Corthals, Carlo Heirman, Kris Thielemans, and Bart Neyns, Vrije Universiteit Brussel; Nicolas van Baren, Ludwig Institute for Cancer Research; Sophie Lucas, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; and Pia Kvistborg, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jurgen Corthals
- Sofie Wilgenhof, Kris Thielemans, and Bart Neyns, Universitair Ziekenhuis Brussel; Sofie Wilgenhof, Jurgen Corthals, Carlo Heirman, Kris Thielemans, and Bart Neyns, Vrije Universiteit Brussel; Nicolas van Baren, Ludwig Institute for Cancer Research; Sophie Lucas, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; and Pia Kvistborg, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Carlo Heirman
- Sofie Wilgenhof, Kris Thielemans, and Bart Neyns, Universitair Ziekenhuis Brussel; Sofie Wilgenhof, Jurgen Corthals, Carlo Heirman, Kris Thielemans, and Bart Neyns, Vrije Universiteit Brussel; Nicolas van Baren, Ludwig Institute for Cancer Research; Sophie Lucas, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; and Pia Kvistborg, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Nicolas van Baren
- Sofie Wilgenhof, Kris Thielemans, and Bart Neyns, Universitair Ziekenhuis Brussel; Sofie Wilgenhof, Jurgen Corthals, Carlo Heirman, Kris Thielemans, and Bart Neyns, Vrije Universiteit Brussel; Nicolas van Baren, Ludwig Institute for Cancer Research; Sophie Lucas, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; and Pia Kvistborg, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Sophie Lucas
- Sofie Wilgenhof, Kris Thielemans, and Bart Neyns, Universitair Ziekenhuis Brussel; Sofie Wilgenhof, Jurgen Corthals, Carlo Heirman, Kris Thielemans, and Bart Neyns, Vrije Universiteit Brussel; Nicolas van Baren, Ludwig Institute for Cancer Research; Sophie Lucas, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; and Pia Kvistborg, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Pia Kvistborg
- Sofie Wilgenhof, Kris Thielemans, and Bart Neyns, Universitair Ziekenhuis Brussel; Sofie Wilgenhof, Jurgen Corthals, Carlo Heirman, Kris Thielemans, and Bart Neyns, Vrije Universiteit Brussel; Nicolas van Baren, Ludwig Institute for Cancer Research; Sophie Lucas, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; and Pia Kvistborg, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Kris Thielemans
- Sofie Wilgenhof, Kris Thielemans, and Bart Neyns, Universitair Ziekenhuis Brussel; Sofie Wilgenhof, Jurgen Corthals, Carlo Heirman, Kris Thielemans, and Bart Neyns, Vrije Universiteit Brussel; Nicolas van Baren, Ludwig Institute for Cancer Research; Sophie Lucas, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; and Pia Kvistborg, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Bart Neyns
- Sofie Wilgenhof, Kris Thielemans, and Bart Neyns, Universitair Ziekenhuis Brussel; Sofie Wilgenhof, Jurgen Corthals, Carlo Heirman, Kris Thielemans, and Bart Neyns, Vrije Universiteit Brussel; Nicolas van Baren, Ludwig Institute for Cancer Research; Sophie Lucas, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; and Pia Kvistborg, The Netherlands Cancer Institute, Amsterdam, the Netherlands
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13
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Spain L, Diem S, Larkin J. Management of toxicities of immune checkpoint inhibitors. Cancer Treat Rev 2016; 44:51-60. [PMID: 26874776 DOI: 10.1016/j.ctrv.2016.02.001] [Citation(s) in RCA: 593] [Impact Index Per Article: 74.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibition with the anti-CTLA-4 antibody ipilimumab and the anti-PD-1 antibodies nivolumab and pembrolizumab has improved survival in metastatic melanoma, lung cancer and renal cancer. Use of these agents holds promise in other malignancies. The augmented immune response enabled by these agents has led to a particular group of side effects called immune-related adverse events (irAEs). The main irAEs include diarrhea, colitis, hepatitis, skin toxicities and endocrinopathies such as hypophysitis and thyroid dysfunction. The anti-PD-1 antibodies have a different toxicity profile to ipilimumab with fewer high grade events. This article identifies the rates of common and uncommon irAEs associated with each immune checkpoint inhibitor (ICPI) and their timing of onset, focusing mainly on the experience in melanoma and lung cancer. An approach to management for each class of irAE is provided.
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Affiliation(s)
- Lavinia Spain
- Melanoma Unit, Royal Marsden Foundation Trust, Fulham Road, London SW3 6JJ, United Kingdom
| | - Stefan Diem
- Melanoma Unit, Royal Marsden Foundation Trust, Fulham Road, London SW3 6JJ, United Kingdom
| | - James Larkin
- Melanoma Unit, Royal Marsden Foundation Trust, Fulham Road, London SW3 6JJ, United Kingdom.
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Schoenfeld JD, Mahadevan A, Floyd SR, Dyer MA, Catalano PJ, Alexander BM, McDermott DF, Kaplan ID. Ipilmumab and cranial radiation in metastatic melanoma patients: a case series and review. J Immunother Cancer 2015; 3:50. [PMID: 26672895 PMCID: PMC4678639 DOI: 10.1186/s40425-015-0095-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 10/14/2015] [Indexed: 11/25/2022] Open
Abstract
Background Ipilimumab improves survival in metastatic melanoma patients. This population frequently develops brain metastases, which have been associated with poor survival and are often treated with radiation. Therefore, outcomes following ipilimumab and radiation are of interest, especially given case reports and animal studies suggest combined treatment may generate abscopal responses outside the radiation field. Findings We reviewed sixteen consecutive melanoma patients who received 1 to 8 courses of radiation, with a sum total of 51, systematically evaluating abscopal responses by following the largest extra-cranial lesion. We also reviewed other series of patients treated with cranial radiation and ipilimumab. Our patients received between 1 and 8 courses of cranial radiation. Four patients received radiation concurrently with ipilimumab. Median survival was 14 months, and 17 months in patients initially treated with SRS. Interestingly, after radiotherapy, there was a 2.8-fold increased likelihood that the rate of extra-cranial index lesion response improved that didn’t reach statistical significance (p = 0.07); this was more pronounced when ipilimumab was administered within three months of radiation (p < 0.01). Conclusion Our experience and review of recently published series suggest ipilimumab and cranial radiation is well tolerated and can result in prolonged survival. Timing of ipilimumab administration in relation to radiation may impact outcomes. Additionally, our results demonstrate a trend for favorable systemic response following radiotherapy worthy of further evaluation in studies powered to detect potential synergies between radiation and immunotherapy.
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Affiliation(s)
- Jonathan D Schoenfeld
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, 450 Brookline Ave, DA L2-57, 02114 Boston, MA USA
| | - Anand Mahadevan
- Department of Radiation Oncology, Beth Israel Deaconess Hospital, Boston, MA USA
| | - Scott R Floyd
- Department of Radiation Oncology, Beth Israel Deaconess Hospital, Boston, MA USA ; Department of Radiation Oncology, Duke Medical School, Durham, NC USA
| | | | - Paul J Catalano
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, 450 Brookline Ave, DA L2-57, 02114 Boston, MA USA
| | - Brian M Alexander
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, 450 Brookline Ave, DA L2-57, 02114 Boston, MA USA
| | | | - Irving D Kaplan
- Department of Radiation Oncology, Beth Israel Deaconess Hospital, Boston, MA USA
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Jones PS, Cahill DP, Brastianos PK, Flaherty KT, Curry WT. Ipilimumab and craniotomy in patients with melanoma and brain metastases: a case series. Neurosurg Focus 2015; 38:E5. [PMID: 25727227 DOI: 10.3171/2014.12.focus14698] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECT In patients with large or symptomatic brain lesions from metastatic melanoma, the value of resection of metastases to facilitate administration of systemic ipilimumab therapy has not yet been described. The authors undertook this study to investigate whether craniotomy creates the opportunity for patients to receive and benefit from ipilimumab who would otherwise succumb to brain metastasis prior to the onset of regression. METHODS All patients with metastatic melanoma who received ipilimumab and underwent craniotomy for metastasis resection between 2008 and 2014 at the Massachusetts General Hospital were identified through retrospective chart review. The final analysis included cases involving patients who underwent craniotomy within 3 months prior to initiation of therapy or up to 6 months after cessation of ipilimumab administration. RESULTS Twelve patients met the inclusion criteria based on timing of therapy (median age 59.2). The median number of metastases at the time of craniotomy was 2. The median number of ipilimumab doses received was 4. Eleven of 12 courses of ipilimumab were stopped for disease progression, and 1 was stopped for treatment-induced colitis. Eight of 12 patients had improvement in their performance status following craniotomy. Of the 6 patients requiring corticosteroids prior to craniotomy, 3 tolerated corticosteroid dose reduction after surgery. Ten of 12 patients had died by the time of data collection, with 1 patient lost to follow-up. The median survival after the start of ipilimumab treatment was 7 months. CONCLUSIONS In this series, patients who underwent resection of brain metastases in temporal proximity to receiving ipilimumab had qualitatively improved performance status following surgery in most cases. Surgery facilitated corticosteroid reduction in select patients. Larger analyses are required to better understand possible synergies between craniotomy for melanoma metastases and ipilimumab treatment.
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Abstract
Ipilimumab, a fully human anti-CTLA-4 antibody, has been approved for the treatment of
unresectable or metastatic melanoma based on its survival benefit demonstrated in
randomized phase III studies. The current approved dosing schedule of ipilimumab is
3 mg/kg as a 90-min intravenous infusion every 3 weeks for a total of 4 doses. The
immune-mediated mechanism of action of ipilimumab can result in tumor response patterns
that may differ from those observed with conventional chemotherapy; therefore, revised
response criteria to fully capture the spectrum of responses have been developed and are
being prospectively validated. The safety profile of ipilimumab also reflects its
mechanism of action and is characterized by immune-related adverse events. Although most
of these events are mild, tolerable and reversible, high-grade immune-related adverse
events have been observed in 15% of patients and can be potentially life-threatening if
not managed appropriately. Guidelines for the management of these events emphasize
thorough patient education, vigilant monitoring and prompt intervention with
corticosteroids when appropriate. Ongoing research, including evaluation of ipilimumab in
the adjuvant setting, investigation of its use in combination with other agents and
assessment of alternative doses, will help optimize and expand the use of this innovative
treatment.
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Affiliation(s)
- Van Anh Trinh
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Boasberg P, Hamid O, O'Day S. Ipilimumab: unleashing the power of the immune system through CTLA-4 blockade. Semin Oncol 2010; 37:440-9. [PMID: 21074058 DOI: 10.1053/j.seminoncol.2010.09.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Malignant melanoma is rising faster in incidence than any other malignancy. Long-term remission or "cure" is rare and is almost exclusively limited to therapies that stimulate an immune antitumor response. Ipilimumab is a novel targeted human immunostimulatory monoclonal antibody that blocks cytotoxic T-lymphocyte antigen4 (CTLA-4), an immune-inhibitory site expressed on activated T cells. Ipilimumab is well tolerated as an outpatient infusion therapy. Multiple studies have confirmed significant antimelanoma activity. A randomized trial has documented a survival benefit when ipilimumab was compared to a gp-100 vaccine only arm. The unique mechanism of action of ipilimumab makes assessment of response by conventional criteria difficult. Benefit from ipilimumab can occur after what would be considered progression with World Health Oganization (WHO) or Response Evaluation Criteria in Solid Tumors (RECIST) criteria. New immune response criteria have been proposed. Therapeutic responses peak between 12 and 24 weeks, with slow responses continuing up to and beyond 12 months. The major drug- related adverse side effects (10%-15% grade 3 or above) are immune-related and consist most commonly of rash, colitis, hypophysitis, thyroiditis, and hepatitis. Colonic perforation can occur and patients with diarrhea have to be monitored carefully with strict adherence to treatment algorithms. Algorithms for the treatment of other adverse side effects have been developed. The treatment of immune-related side effects with immunosuppressive agents, such as corticosteroids, does not appear to impair antitumor response. With proper monitoring and management of side effects, ipilimumab is an extremely safe drug to administer. The benefits of ipilimumab will most certainly extend to other malignancies in the near future.
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Affiliation(s)
- Peter Boasberg
- The Angeles Clinic & Research Institute, 2001 Santa Monica Blvd, Suite 560W, Santa Monica, CA 90404, USA.
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Hoos A, Ibrahim R, Korman A, Abdallah K, Berman D, Shahabi V, Chin K, Canetta R, Humphrey R. Development of Ipilimumab: Contribution to a New Paradigm for Cancer Immunotherapy. Semin Oncol 2010; 37:533-46. [DOI: 10.1053/j.seminoncol.2010.09.015] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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