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Purcell V, Preti B, Fernandes R. Suspected immune checkpoint inhibitor-induced pulmonary sarcoid reaction in metastatic renal cell carcinoma. Clin Case Rep 2022; 10:e5960. [PMID: 35846932 PMCID: PMC9272222 DOI: 10.1002/ccr3.5960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/19/2022] [Accepted: 05/30/2022] [Indexed: 01/09/2023] Open
Abstract
We present the case of a 50-year-old male patient with metastatic clear cell renal cell carcinoma (mRCC) who developed a diffuse pulmonary opacification and lymphadenopathy during nivolumab maintenance therapy. This was diagnosed as presumed sarcoid granulomatous inflammatory reaction secondary to immunotherapy, which resolved with holding off therapy and the nivolumab was resumed.
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Affiliation(s)
- Victoria Purcell
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| | - Beatrice Preti
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada,Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada
| | - Ricardo Fernandes
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada,Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada,Cancer Research Laboratory ProgramLawson Health Research InstituteLondonOntarioCanada
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2
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Rapoport BL, Shannon VR, Cooksley T, Johnson DB, Anderson L, Blidner AG, Tintinger GR, Anderson R. Pulmonary Toxicities Associated With the Use of Immune Checkpoint Inhibitors: An Update From the Immuno-Oncology Subgroup of the Neutropenia, Infection & Myelosuppression Study Group of the Multinational Association for Supportive Care in Cancer. Front Pharmacol 2021; 12:743582. [PMID: 34675810 PMCID: PMC8523897 DOI: 10.3389/fphar.2021.743582] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022] Open
Abstract
The development of immune checkpoint inhibitors (ICIs) has revolutionized cancer treatment, with agents such as nivolumab, pembrolizumab, and cemiplimab targeting programmed cell death protein-1 (PD-1) and durvalumab, avelumab, and atezolizumab targeting PD-ligand 1 (PD-L1). Ipilimumab targets cytotoxic T lymphocyte-associated antigen-4 (CTLA-4). These inhibitors have shown remarkable efficacy in melanoma, lung cancer, urothelial cancer, and a variety of solid tumors, either as single agents or in combination with other anticancer modalities. Additional indications are continuing to evolve. Checkpoint inhibitors are associated with less toxicity when compared to chemotherapy. These agents enhance the antitumor immune response and produce side- effects known as immune-related adverse events (irAEs). Although the incidence of immune checkpoint inhibitor pneumonitis (ICI-Pneumonitis) is relatively low, this complication is likely to cause the delay or cessation of immunotherapy and, in severe cases, may be associated with treatment-related mortality. The primary mechanism of ICI-Pneumonitis remains unclear, but it is believed to be associated with the immune dysregulation caused by ICIs. The development of irAEs may be related to increased T cell activity against cross-antigens expressed in tumor and normal tissues. Treatment with ICIs is associated with an increased number of activated alveolar T cells and reduced activity of the anti-inflammatory Treg phenotype, leading to dysregulation of T cell activity. This review discusses the pathogenesis of alveolar pneumonitis and the incidence, diagnosis, and clinical management of pulmonary toxicity, as well as the pulmonary complications of ICIs, either as monotherapy or in combination with other anticancer modalities, such as thoracic radiotherapy.
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Affiliation(s)
- Bernardo L Rapoport
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,The Medical Oncology Centre of Rosebank, Johannesburg, South Africa.,The Multinational Association for Supportive Care in Cancer (MASCC), Immuno-Oncology Subgroup of the Neutropenia, Infection and Myelosuppression Study Group, Manchester, United Kingdom
| | - Vickie R Shannon
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Tim Cooksley
- The Multinational Association for Supportive Care in Cancer (MASCC), Immuno-Oncology Subgroup of the Neutropenia, Infection and Myelosuppression Study Group, Manchester, United Kingdom.,Manchester University Foundation Trust, Manchester, United Kingdom.,The Christie, University of Manchester, Manchester, United Kingdom
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Centre and Vanderbilt Ingram Cancer Center, Nashville, TN, United States
| | - Lindsay Anderson
- Department of Radiation Oncology, Steve Biko Academic Hospital, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Ada G Blidner
- Laboratory of Immunopathology, Institute of Biology and Experimental Medicine, CONICET, Buenos Aires, Argentina
| | - Gregory R Tintinger
- Department of Internal Medicine, Steve Biko Academic Hospital, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,The Multinational Association for Supportive Care in Cancer (MASCC), Immuno-Oncology Subgroup of the Neutropenia, Infection and Myelosuppression Study Group, Manchester, United Kingdom
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3
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Kubo T, Hirohashi Y, Tsukahara T, Kanaseki T, Murata K, Morita R, Torigoe T. Immunopathological basis of immune-related adverse events induced by immune checkpoint blockade therapy. Immunol Med 2021; 45:108-118. [PMID: 34542015 DOI: 10.1080/25785826.2021.1976942] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Despite the considerable success of cancer immunotherapy with immune checkpoint inhibitors, their nonspecific release of the immunosuppressive mechanism is often associated with immune-related adverse events (irAEs). irAEs significantly disturb patients' quality of life and can even be life-threatening. Therefore, the appropriate management of irAEs is crucial for the development of further reliable cancer immunotherapies. irAEs have the appearance of ordinary autoimmune diseases in one aspect but often have distinct features. Although the detailed pathogenesis of irAEs remains unclear, increasing numbers of studies have provided numerous clues. Here, we review the current knowledge on irAEs, particularly from an immunopathological basis.
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Affiliation(s)
- Terufumi Kubo
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Yoshihiko Hirohashi
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Tomohide Tsukahara
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Takayuki Kanaseki
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Kenji Murata
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Rena Morita
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan.,Division of Fundamental Health Sciences, School of Nursing and Social Services, Health Sciences University of Hokkaido, Tobetsu, Japan
| | - Toshihiko Torigoe
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
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4
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Coronavirus disease 2019 vaccine mimics lymph node metastases in patients undergoing skin cancer follow-up: A monocentre study. Eur J Cancer 2021; 154:167-174. [PMID: 34280870 PMCID: PMC8233908 DOI: 10.1016/j.ejca.2021.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 11/23/2022]
Abstract
Introduction The coronavirus disease 2019 (COVID-19) pandemic has changed the lives of people around the world. Fortunately, sufficient vaccines are now available. Local reactions with ipsilateral lymphadenopathy are among the most common side effects. We investigated the impact of lymphadenopathy after COVID-19 vaccination on the value of ultrasound in tumour patients. Patients and methods Patients with melanoma or Merkel cell carcinoma were included who underwent lymph node excision and received COVID-19 vaccination within 6 weeks before surgery. The consistency of the preoperative ultrasound findings with the histopathologic findings was investigated. Results Eight patients were included (two Merkel cell carcinoma and six melanoma patients) who underwent lymph node excision between 16th April 2021 and 19th May 2021 and had previously received COVID-19 vaccination. In three of the eight patients (one Merkel cell carcinoma and two melanoma patients), lymph node metastases were erroneously diagnosed preoperatively during tumour follow-up with physical examination, ultrasound, and or fluorodeoxyglucose (FDG)–positron emission tomography (PET)/computed tomography (CT). In these three patients, the suspected lymph node metastases were located in the left axilla after COVID-19 vaccination in the left upper arm, which resulted in selective lymph node removal in two patients and complete lymphadenectomy in one patient. Conclusion COVID-19 vaccine–associated lymphadenopathy is expected to be observed much more frequently in the near future because of increasing vaccination rates. This cause of lymphadenopathy, which may in ultrasound as well as in FDG PET/CT resemble lymph node metastases, must be considered, especially in oncologic patients undergoing tumour follow-up. In addition, COVID-19 vaccination should be given as far away as possible from an underlying primary on the contralateral side to avoid oncologic misdiagnosis followed by malpractice.
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5
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Sakellariou S, Zouki DN, Ziogas DC, Pouloudi D, Gogas H, Delladetsima I. Granulomatous colitis in a patient with metastatic melanoma under immunotherapy: a case report and literature review. BMC Gastroenterol 2021; 21:227. [PMID: 34011268 PMCID: PMC8136206 DOI: 10.1186/s12876-021-01812-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 05/11/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICPIs) have changed the way advanced malignancies are currently confronted, improving cancer patients' outcomes but also generating distinct immune-related (ir) adverse events. ICPIs-induced colitis is a common complication showing different clinical and histological manifestations. In the literature review, 14 cases with ICPIs related colon granulomas have been reported in 5 studies with either limited or unavailable information regarding histology. Granulomatous reactions can be mistakenly perceived as disease recurrence or progression. Better understanding and identification of this infrequent histological display can help to avoid misdiagnosis and mismanagement. CASE PRESENTATION A 63-year-old female patient with metastatic melanoma was admitted to the hospital with symptoms of nausea, persistent diarrhea and shivering fever under consecutive treatments with ICPIs, initially pembrolizumab and subsequently ipilimumab. Sigmoidoscopy was performed revealing mucosal edema, hyperemia and erosions of the rectum and sigmoid colon. Histological evaluation of sigmoid colon mucosa biopsies revealed an unusual colitis pattern characterized by multiple intracryptal granulomas attributed to ICPIs therapy. Steroids were administered and the patient recovered. ICPIs treatment was discontinued. The patient was subsequently treated with chemotherapy but follow up radiology showed disease progression. A re-challenge with another ICPI regimen was decided and the patient is currently under immunotherapy with stable disease regarding melanoma status and without any sign of colitis recurrence. CONCLUSIONS The present report provides detailed histological description of a distinctive ICPIs-induced granulomatous colitis and highlights the need for awareness of the distinct adverse events and reaction patterns in the context of immunotherapy.
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Affiliation(s)
- Stratigoula Sakellariou
- First Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75, Mikras Asias street, 11527, Athens, Greece.
| | - Dionysia N Zouki
- First Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75, Mikras Asias street, 11527, Athens, Greece
| | - Dimitrios C Ziogas
- First Department of Internal Medicine, Laiko General Hospital School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Despoina Pouloudi
- First Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75, Mikras Asias street, 11527, Athens, Greece
| | - Helen Gogas
- First Department of Internal Medicine, Laiko General Hospital School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Delladetsima
- First Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75, Mikras Asias street, 11527, Athens, Greece
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6
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Rubio-Rivas M, Moreira C, Marcoval J. Sarcoidosis related to checkpoint and BRAF/MEK inhibitors in melanoma. Autoimmun Rev 2020; 19:102587. [DOI: 10.1016/j.autrev.2020.102587] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/01/2020] [Indexed: 12/11/2022]
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Chorti E, Kanaki T, Zimmer L, Hadaschik E, Ugurel S, Gratsias E, Roesch A, Bonella F, Wessendorf TE, Wälscher J, Theegarten D, Schadendorf D, Livingstone E. Drug-induced sarcoidosis-like reaction in adjuvant immunotherapy: Increased rate and mimicker of metastasis. Eur J Cancer 2020; 131:18-26. [PMID: 32248071 DOI: 10.1016/j.ejca.2020.02.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/07/2020] [Accepted: 02/17/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Anti-[programmed cell death protein 1 (PD-1)] antibodies nivolumab and pembrolizumab were approved for adjuvant treatment of melanoma as they demonstrated improved relapse-free survival. Currently, combined anti-PD-1 plus anti-[cytotoxic T-lymphocyte-associated protein 4 (CTLA4)] blockade is being investigated in adjuvant and neoadjuvant trials. Sarcoidosis-like reactions have been described for immune checkpoint inhibitors and are most likely drug-induced. The reported rate of sarcoidosis/sarcoidosis-like reactions within clinical melanoma trials is <2%. We observed that a remarkably higher number of melanoma patients (10/45 patients, 22%) treated with immune checkpoint inhibitor (ICI) within an adjuvant clinical trial-developed drug induced sarcoidosis-like reaction (DISR) mimicking metastasis. CASE PRESENTATION Of 45 stage III melanoma patients who were treated at our institute with adjuvant ICI (either nivolumab alone or in combination with ipilimumab) within a two-armed, blinded clinical trial, ten developed a DISR. Three of the ten patients were men, median age was 52 years (range, 32-70 years). DISRs were asymptomatic and generally detected radiographically at first radiographic imaging after the start of therapy (median time, 2.8 months) and described as a differential diagnosis to tumour progression. In one patient, DISR was only apparent 13.1 months after start of therapy and 4 weeks after the end of ICI treatment. DISR presented as mediastinal/hilar lymphadenopathy in 8/10 patients (as only site or in addition to lung, skin and/or bone involvement), one patient had only lung and cutaneous, one patient only cutaneous DISR. Biopsies from lymph nodes, skin and bone were taken in 8/10 patients, and histology confirmed sarcoidosis-like reactions (SLRs). As patients were asymptomatic, no treatment for DISR was required, and study treatment was stopped for DISR in only one patient due to bone involvement. DISRs have resolved or are in remission in all patients. At a median follow-up time of 15.3 months (range, 12-17.6 months), two patients experienced melanoma relapse. CONCLUSIONS In most cases, sarcoidosis could only be differentiated from melanoma progression on biopsy. Treating physicians as well as radiologists have to be aware of the potentially higher rate of DISR in patients receiving adjuvant ICI. A thorough interdisciplinary workup is required to discriminate from true melanoma progression and to decide on continuation of adjuvant ICI treatment.
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Affiliation(s)
- Eleftheria Chorti
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany.
| | - Theodora Kanaki
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Lisa Zimmer
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Eva Hadaschik
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Selma Ugurel
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Emmanouil Gratsias
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Alexander Roesch
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Francesco Bonella
- Dept. of Pulmonary Medicine, Center for Interstitial and Rare Lung Diseases, Ruhrlandklinik University Hospital Essen, Tüschener Weg 40, 45239 Essen, Germany
| | - Thomas E Wessendorf
- Dept. of Pulmonary Medicine, Center for Interstitial and Rare Lung Diseases, Ruhrlandklinik University Hospital Essen, Tüschener Weg 40, 45239 Essen, Germany
| | - Julia Wälscher
- Dept. of Pulmonary Medicine, Center for Interstitial and Rare Lung Diseases, Ruhrlandklinik University Hospital Essen, Tüschener Weg 40, 45239 Essen, Germany
| | - Dirk Theegarten
- Institute of Pathology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Dirk Schadendorf
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Elisabeth Livingstone
- Dept. of Dermatology, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
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8
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Zhang D, Hart J, Ding X, Zhang X, Feely M, Yassan L, Alpert L, Soldevila-Pico C, Zhang X, Liu X, Lai J. Histologic patterns of liver injury induced by anti-PD-1 therapy. Gastroenterol Rep (Oxf) 2019; 8:50-55. [PMID: 32467761 PMCID: PMC7244961 DOI: 10.1093/gastro/goz044] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/16/2019] [Accepted: 08/16/2019] [Indexed: 02/05/2023] Open
Abstract
Background Nivolumab and pembrolizumab—two monoclonal antibodies that block human programmed cell death-1 (PD-1)—have been successfully used to treat patients with multiple advanced malignancies. The histologic patterns of hepatic toxicity induced by anti-PD-1 treatment have not been well studied and the aim of this study was to explore them. Methods Eight patients with advanced malignancies who were treated with either nivolumab or pembrolizumab were identified from five institutions. These patients had no history of underlying liver disease and a viral hepatitis panel was negative in all patients. Results Seven of eight patients exhibited mild to moderate gastrointestinal symptoms such as abdominal pain, fatigue, nausea, vomiting, and jaundice after anti-PD-1 treatment. Significant elevations in liver-chemistry tests were detected in all patients. Six cases (6/8) demonstrated an acute lobular hepatitis pattern of histologic injury. The remaining two cases showed different histologic patterns of injury: steatohepatitis with mild cholestasis (1/8) and pure acute cholestatic injury (1/8). No case showed typical features of autoimmune hepatitis. The liver function recovered in all eight cases after cessation of anti-PD-1 agents and with immunosuppressive therapy. Conclusions Our study suggests that screening patients for abnormal liver-function tests prior to anti-PD-1 therapy as well as periodic monitoring of liver-function tests are necessary to prevent severe liver injury. Rather than causing classical autoimmune hepatitis, PD-1 inhibitors appear to produce an immune-mediated nonspecific acute hepatitis. Drug cessation, without steroid therapy, may therefore be sufficient in some patients.
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Affiliation(s)
- Dongwei Zhang
- Department of Pathology, Immunology and Laboratory of Medicine, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - John Hart
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Xianzhong Ding
- Department of Pathology and Laboratory of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Xuchen Zhang
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Michael Feely
- Department of Pathology, Immunology and Laboratory of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lindsay Yassan
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Lindsay Alpert
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | | | - Xuefeng Zhang
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Xiuli Liu
- Department of Pathology, Immunology and Laboratory of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jinping Lai
- Department of Pathology, Immunology and Laboratory of Medicine, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Pathology, Kaiser Permanente Sacramento Medical Center, Sacramento, CA, USA
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9
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Puwanant A, Isfort M, Lacomis D, Živković SA. Clinical spectrum of neuromuscular complications after immune checkpoint inhibition. Neuromuscul Disord 2019; 29:127-133. [DOI: 10.1016/j.nmd.2018.11.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/21/2022]
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10
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Anderson D, Beecher G, Nathoo N, Smylie M, McCombe JA, Walker J, Jassal R. Proposed diagnostic and treatment paradigm for high-grade neurological complications of immune checkpoint inhibitors. Neurooncol Pract 2018; 6:340-345. [PMID: 31555448 DOI: 10.1093/nop/npy039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors such as antibodies to cytotoxic lymphocyte-associated protein 4 (ipilimumab) and programmed cell-death 1 (pembrolizumab, nivolumab) molecules have been used in non-small cell lung cancer, metastatic melanoma, and renal-cell carcinoma, among others. With these agents, immune-related adverse events (irAEs) can occur, including those affecting the neurological axis. In this review, high-grade neurological irAEs associated with immune checkpoint inhibitors including cases of Guillain-Barré syndrome (GBS) and myasthenia gravis (MG) are analyzed. Based on current literature and experience at our institution with 4 cases of high-grade neurological irAEs associated with immune checkpoint inhibitors (2 cases of GBS, 1 case of meningo-radiculitis, and 1 case of myelitis), we propose an algorithm for the investigation and treatment of high-grade neurological irAEs. Our algorithm incorporates both peripheral nervous system (meningo-radiculitis, GBS, MG) and central nervous system presentations (myelitis, encephalopathy). It is anticipated that our algorithm will be useful both to oncologists and neurologists who are likely to encounter neurological irAEs more frequently in the future as immune checkpoint inhibitors become more widely used.
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Affiliation(s)
- Dustin Anderson
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - Grayson Beecher
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - Nabeela Nathoo
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - Michael Smylie
- Department of Oncology (Medical Oncology), University of Alberta, Edmonton, Canada
| | - Jennifer A McCombe
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - John Walker
- Department of Oncology (Medical Oncology), University of Alberta, Edmonton, Canada
| | - Rajive Jassal
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
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11
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Cornejo CM, Haun P, English J, Rosenbach M. Immune checkpoint inhibitors and the development of granulomatous reactions. J Am Acad Dermatol 2018; 81:1165-1175. [PMID: 30092327 DOI: 10.1016/j.jaad.2018.07.051] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/21/2018] [Accepted: 07/18/2018] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors (ICPIs) have emerged as a frontline treatment for a growing list of malignancies. Disruption of the negative regulatory immune checkpoints by ICPIs has been associated with many immune-related adverse events. Granulomatous reactions, such as sarcoidosis-like reactions, granulomatous panniculitis, granuloma annulare, and granulomatous dermatitis, are uncommon but increasingly recognized immune-related adverse events seen in patients treated with ICPIs. The frequency and significance of these eruptions, including whether they portend responsiveness to treatment, remain unclear. Additionally, understanding the role of immune checkpoint blockade in these reactions may provide mechanistic insight into the relevant signaling pathways involved in sarcoidosis and other granulomatous disorders.
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Affiliation(s)
- Christine M Cornejo
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Paul Haun
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph English
- Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Gkiozos I, Kopitopoulou A, Kalkanis A, Vamvakaris IN, Judson MA, Syrigos KN. Sarcoidosis-Like Reactions Induced by Checkpoint Inhibitors. J Thorac Oncol 2018; 13:1076-1082. [PMID: 29763666 DOI: 10.1016/j.jtho.2018.04.031] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/29/2018] [Accepted: 04/30/2018] [Indexed: 12/11/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are a newly developed component of cancer care that expands the treatment possibilities for patients. Their use has been associated with several immune-related adverse events, including ICI-induced sarcoidosis-like reactions. This article reviews the data concerning ICI-induced sarcoidosis-like reactions currently available in the medical literature. These reactions have been reported in three classes of ICIs: anti-cytotoxic T-lymphocyte associated protein 4 antibodies, programmed death 1 inhibitors and programmed death ligand 1 inhibitors. These reactions are indistinguishable from sarcoidosis with a similar histology, pattern of organ involvement, and pattern of clinical manifestations. The most common locations to observe granulomatous inflammation from these reactions is in intrathoracic locations (the lung and/or mediastinal lymph nodes) and the skin. The median time between initiation of an ICI and the development of a sarcoidosis-like reaction averaged 14 weeks. Clinicians have opted to use corticosteroids and/or discontinue the ICI, or take no action when these reactions have developed. Regardless of whether the clinician performed an intervention or not, these reactions have uniformly improved or resolved after ICI-treatment, which provides additional temporal evidence supporting the presence of a sarcoidosis-like reaction as opposed to sarcoidosis. There is even evidence that the development of an ICI-induced sarcoidosis-like reaction suggests that the ICI is effective as an anti-tumor agent and should be continued. As is the case for sarcoidosis, sarcoidosis-like reactions do not mandate antisarcoidosis therapy, especially if the condition is asymptomatic. When treatment of sarcoidosis-like reaction is required, it may be prudent to continue ICI therapy and add antisarcoidosis therapy because standard antisarcoidosis regimens seem to be effective. Further research into the mechanisms involved in the development of ICI-induced sarcoidosis-like reactions may give insights into the immunopathogenesis of sarcoidosis.
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Affiliation(s)
- Ioannis Gkiozos
- Third Department of Medicine, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece.
| | - Alexandra Kopitopoulou
- Third Department of Medicine, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Kalkanis
- Division of Pulmonary and Critical Care Medicine, 401 Military and VA Hospital, Athens, Greece
| | - Ioannis N Vamvakaris
- First Pathology Department, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York
| | - Konstantinos N Syrigos
- Third Department of Medicine, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
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13
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Chopra A, Nautiyal A, Kalkanis A, Judson MA. Drug-Induced Sarcoidosis-Like Reactions. Chest 2018; 154:664-677. [PMID: 29698718 DOI: 10.1016/j.chest.2018.03.056] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 01/02/2023] Open
Abstract
A drug-induced sarcoidosis-like reaction (DISR) is a systemic granulomatous reaction that is indistinguishable from sarcoidosis and occurs in a temporal relationship with initiation of an offending drug. DISRs typically improve or resolve after withdrawal of the offending drug. Four common categories of drugs that have been associated with the development of a DISR are immune checkpoint inhibitors, highly active antiretroviral therapy, interferons, and tumor necrosis factor-α antagonists. Similar to sarcoidosis, DISRs do not necessarily require treatment because they may cause no significant symptoms, quality of life impairment, or organ dysfunction. When treatment of a DISR is required, standard antisarcoidosis regimens seem to be effective. Because a DISR tends to improve or resolve when the offending drug is discontinued, this is another effective treatment for a DISR. However, the offending drug need not be discontinued if it is useful, and antigranulomatous therapy can be added. In some situations, the development of a DISR may suggest a beneficial effect of the inducing drug. Understanding the mechanisms leading to DISRs may yield important insights into the immunopathogenesis of sarcoidosis.
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Affiliation(s)
- Amit Chopra
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY.
| | - Amit Nautiyal
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY
| | - Alexander Kalkanis
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, 401 Military and VA Hospital, Athens, Greece
| | - Marc A Judson
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY
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Sepúlveda M, Martinez-Hernandez E, Gaba L, Victoria I, Sola-Valls N, Falgàs N, Casanova-Molla J, Graus F. Motor polyradiculopathy during pembrolizumab treatment of metastatic melanoma. Muscle Nerve 2017; 56:E162-E167. [DOI: 10.1002/mus.25672] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 03/23/2017] [Accepted: 04/17/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Maria Sepúlveda
- Department of Neurology; Hospital Clínic, University of Barcelona; Barcelona Spain
- Neuroimmunology Program; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona Spain
| | - Eugenia Martinez-Hernandez
- Department of Neurology; Hospital Clínic, University of Barcelona; Barcelona Spain
- Neuroimmunology Program; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona Spain
| | - Lydia Gaba
- Medical Oncology Department; Hospital Clínic, University of Barcelona; Barcelona Spain
| | - Ivan Victoria
- Medical Oncology Department; Hospital Clínic, University of Barcelona; Barcelona Spain
| | - Nuria Sola-Valls
- Department of Neurology; Hospital Clínic, University of Barcelona; Barcelona Spain
- Neuroimmunology Program; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona Spain
| | - Neus Falgàs
- Department of Neurology; Hospital Clínic, University of Barcelona; Barcelona Spain
| | - Jordi Casanova-Molla
- Department of Neurology; Hospital Clínic, University of Barcelona; Barcelona Spain
| | - Francesc Graus
- Department of Neurology; Hospital Clínic, University of Barcelona; Barcelona Spain
- Neuroimmunology Program; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona Spain
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15
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Danlos FX, Pagès C, Baroudjian B, Vercellino L, Battistella M, Mimoun M, Jebali M, Bagot M, Tazi A, Lebbé C. Nivolumab-Induced Sarcoid-Like Granulomatous Reaction in a Patient With Advanced Melanoma. Chest 2017; 149:e133-6. [PMID: 27157227 DOI: 10.1016/j.chest.2015.10.082] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/29/2015] [Accepted: 10/01/2015] [Indexed: 01/04/2023] Open
Abstract
To our knowledge, we report the first case of sarcoid-like granulomatous reaction induced by nivolumab, a fully human IgG4 anti-programmed death 1 (PD-1) immune checkpoint inhibitor antibody. A 57-year-old man was treated with nivolumab 3 mg/kg for 2 weeks for a desmoplastic melanoma stage III American Joint Commission on Cancer, with no BRAF, NRAS, and cKit mutations. At 10 months, although melanoma complete response was achieved, he developed sarcoid-like granulomatous reaction in the mediastinal lymph node and skin, which resumed after nivolumab arrest. Melanoma did not relapse after 12 months of follow-up. Considering the recently demonstrated role of activated PD-1/PDL-1 axis in sarcoidosis, granulomatous reaction in the patient seems to be a paradoxical reaction, but similar observations have been reported with ipilimumab, another immune checkpoint inhibitor. Sarcoid-like granulomatous reaction during immunotherapy treatment could be a manifestation of cell-mediated immunity induced by these drugs. Impact of granulomatous reaction induced by immune checkpoint inhibitor on melanoma progression is not known and requires further study. Melanoma patients treated by immunotherapy (anti-cytotoxic T-lymphocyte-associated protein-4/anti-PD-1) should be considered for developing sarcoid-like granulomatous reaction that must not be confused with tumor progression.
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Affiliation(s)
- François-Xavier Danlos
- Dermatology Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France.
| | - Cécile Pagès
- Dermatology Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France; Clinical Investigation Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France
| | - Barouyr Baroudjian
- Dermatology Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France; Clinical Investigation Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France
| | - Laetitia Vercellino
- Nuclear Medicine Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France
| | - Maxime Battistella
- Pathology Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France
| | - Maurice Mimoun
- Plastic Surgery Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France
| | - Majdi Jebali
- Dermatology Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France; Clinical Investigation Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France
| | - Martine Bagot
- Dermatology Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France; Onco-Dermatology, Immunology and Cutaneous Stem Cells, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Abdellatif Tazi
- Pneumology Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France; Biostatistics and Clinical Epidemiology research team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Céleste Lebbé
- Dermatology Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France; Clinical Investigation Department, Assistance Publique - Hôpitaux de Paris, Saint Louis Hospital, Paris, France; Onco-Dermatology, Immunology and Cutaneous Stem Cells, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
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Cuzzubbo S, Javeri F, Tissier M, Roumi A, Barlog C, Doridam J, Lebbe C, Belin C, Ursu R, Carpentier AF. Neurological adverse events associated with immune checkpoint inhibitors: Review of the literature. Eur J Cancer 2017; 73:1-8. [PMID: 28064139 DOI: 10.1016/j.ejca.2016.12.001] [Citation(s) in RCA: 336] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 12/06/2016] [Indexed: 12/14/2022]
Abstract
Immune checkpoint inhibitors (ICIs) targeting CTLA4 and PD1 constitute a promising class of cancer treatment but are associated with several immune-related disorders. We here review the literature reporting neurological adverse events (nAEs) associated with ICIs. A systematic search of literature, up to February 2016, mentioning nAEs in patients treated with ICIs was conducted. Eligible studies included case reports and prospective trials. One case seen in our ward was also added. Within the 59 clinical trials (totalling 9208 patients) analysed, the overall incidence of nAEs was 3.8% with anti-CTLA4 antibodies, 6.1% with anti-PD1 antibodies, and 12.0% with the combination of both. The clinical spectrum of neurological disorders was highly heterogeneous. Most of these nAEs were grade 1-2 and consisted of non-specific symptoms such as headache (55%). The incidence of high grade nAEs was below 1% for all types of treatment. Headaches, encephalopathies and meningitis were the most commonly reported (21%, 19% and 15%, respectively). Among the 27 case reports, the most common nAEs were encephalopathies, meningoradiculoneuritis, Guillain-Barré like syndromes and myasthenic syndromes. The median time of nAEs onset was 6 weeks. In most cases, drug interruption and steroids led to neurological recovery, even in conditions where steroids are not usually recommended such as Guillain-Barré syndrome.
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Affiliation(s)
- S Cuzzubbo
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France; Université Paris 13, UFR de Santé, Médecine et Biologie Humaine, Bobigny, France.
| | - F Javeri
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France
| | - M Tissier
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France
| | - A Roumi
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France
| | - C Barlog
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France; Université Paris 13, UFR de Santé, Médecine et Biologie Humaine, Bobigny, France
| | - J Doridam
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France; Université Paris 13, UFR de Santé, Médecine et Biologie Humaine, Bobigny, France
| | - C Lebbe
- APHP Dermatology and CIC Departments, INSERM U976, Université Paris Diderot, Sorbonne Paris Cité, Hôpital Saint Louis, Paris, France
| | - C Belin
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France; Université Paris 13, UFR de Santé, Médecine et Biologie Humaine, Bobigny, France
| | - R Ursu
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France; Université Paris 13, UFR de Santé, Médecine et Biologie Humaine, Bobigny, France
| | - A F Carpentier
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de Neurologie, Bobigny, France; Université Paris 13, UFR de Santé, Médecine et Biologie Humaine, Bobigny, France
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17
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Tanaka R, Maruyama H, Tomidokoro Y, Yanagiha K, Hirabayashi T, Ishii A, Okune M, Inoue S, Sekine I, Tamaoka A, Fujimoto M. Nivolumab-induced chronic inflammatory demyelinating polyradiculoneuropathy mimicking rapid-onset Guillain-Barré syndrome: a case report. Jpn J Clin Oncol 2016; 46:875-8. [PMID: 27380808 DOI: 10.1093/jjco/hyw090] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/11/2016] [Indexed: 02/03/2023] Open
Abstract
Nivolumab, an anti-programmed death-1-specific monoclonal antibody, has demonstrated a durable response and effect on overall survival and has become one of the standard treatments for patients with advanced melanoma. Reported herein is a case of nivolumab-induced chronic inflammatory demyelinating polyradiculoneuropathy, in which an 85-year-old woman with stage IV melanoma developed grade 1 paresthesia 2 weeks after the initial dose of nivolumab was administered. With continued treatment, the neurological deficiency deteriorated rapidly, mimicking Guillain-Barré syndrome, causing such a dramatic decrease in her activities of daily living that she could no longer function in daily life. Thus, nivolumab treatment was discontinued. A course of intravenous immunoglobulin infusion yielded a dramatic clinical improvement; in particular, improved motor control was observed within a few days. Her initial presentation was suggestive of acute inflammatory demyelinating polyradiculoneuropathy, a subtype of Guillain-Barré syndrome; however, the good response to steroids and exacerbation 8 weeks after the onset were suggestive of chronic inflammatory demyelinating polyradiculoneuropathy induced by nivolumab. This is the first case of Guillain-Barré syndrome-like autoimmune polyradiculoneuropathy induced by programmed death-1/programmed death-ligand 1 inhibitors. Although neurological adverse events related to nivolumab are rare, they can become severe, requiring early diagnosis and intervention. Intravenous immunoglobulin may be considered as an effective initial treatment for patients who develop acute autoimmune nervous system disorders due to nivolumab.
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Affiliation(s)
- Ryota Tanaka
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Hiroshi Maruyama
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Yasushi Tomidokoro
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Kumi Yanagiha
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Takumi Hirabayashi
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Akiko Ishii
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Mari Okune
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Sae Inoue
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Ikuo Sekine
- Department of Oncology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Akira Tamaoka
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki
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18
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Bertrand A, Kostine M, Barnetche T, Truchetet ME, Schaeverbeke T. Immune related adverse events associated with anti-CTLA-4 antibodies: systematic review and meta-analysis. BMC Med 2015; 13:211. [PMID: 26337719 PMCID: PMC4559965 DOI: 10.1186/s12916-015-0455-8] [Citation(s) in RCA: 490] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/18/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Targeting CTLA-4 is a recent strategic approach in cancer control: blocking CTLA-4 enhances an antitumor immunity by promoting T-cell activation and cytotoxic T-lymphocyte proliferation. This induction of a tolerance break against the tumor may be responsible for immune-related adverse events (irAEs). Our objective was to assess the incidence and nature of irAEs in oncologic patients receiving anti-CTLA-4 antibodies (ipilimumab and tremelimumab). METHODS A systematic search of literature up to February 2014 was performed in MEDLINE, EMBASE, and Cochrane databases to identify relevant articles. Paired reviewers independently selected articles for inclusion and extracted data. Pooled incidence was calculated using R(©), package meta. RESULTS Overall, 81 articles were included in the study, with a total of 1265 patients from 22 clinical trials included in the meta-analysis. Described irAEs consisted of skin lesions (rash, pruritus, and vitiligo), colitis, and less frequently hepatitis, hypophysitis, thyroiditis, and some rare events such as sarcoidosis, uveitis, Guillain-Barré syndrome, immune-mediated cytopenia and polymyalgia rheumatic/Horton. The overall incidence of all-grade irAEs was 72 % (95 % CI, 65-79 %). The overall incidence of high-grade irAEs was 24 % (95 % CI, 18-30 %). The risk of developing irAEs was dependent of dosage, with incidence of all-grade irAEs being evaluated to 61 % (95 % CI, 56-66 %) for ipilimumab 3 mg/kg and 79 % (95 % CI, 69-89 %) for ipilimumab 10 mg/kg. Death due to irAEs occurred in 0.86 % of patients. The median time of onset of irAEs was about 10 weeks (IQR, 6-12) after the onset of treatment, corresponding with the first three cycles but varied according to the organ system involved. Such immune activation could also be indicative for tumor-specific T-cell activation and irAE occurrence was associated with clinical response to CTLA-4 blocking in 60 % of patients. CONCLUSION The price of potential long-term survival to metastatic tumors is an atypical immune toxicity, reflecting the mechanism of action of anti-CTLA-4 antibodies. A better knowledge of these irAEs and its management in a multidisciplinary approach will help to reduce morbidity and therapy interruptions.
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Affiliation(s)
- Anne Bertrand
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
| | - Marie Kostine
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
| | - Thomas Barnetche
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
| | - Marie-Elise Truchetet
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
- Laboratoire d'Immunologie, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France.
| | - Thierry Schaeverbeke
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France.
- Unité sous Contrat, Infections à Mycoplasmes et à Chlamydia chez l'Homme, Université de Bordeaux, Bordeaux, France.
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