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Guidon AC, Burton LB, Chwalisz BK, Hillis J, Schaller TH, Amato AA, Betof Warner A, Brastianos PK, Cho TA, Clardy SL, Cohen JV, Dietrich J, Dougan M, Doughty CT, Dubey D, Gelfand JM, Guptill JT, Johnson DB, Juel VC, Kadish R, Kolb N, LeBoeuf NR, Linnoila J, Mammen AL, Martinez-Lage M, Mooradian MJ, Naidoo J, Neilan TG, Reardon DA, Rubin KM, Santomasso BD, Sullivan RJ, Wang N, Woodman K, Zubiri L, Louv WC, Reynolds KL. Consensus disease definitions for neurologic immune-related adverse events of immune checkpoint inhibitors. J Immunother Cancer 2021; 9:e002890. [PMID: 34281989 PMCID: PMC8291304 DOI: 10.1136/jitc-2021-002890] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2021] [Indexed: 12/12/2022] Open
Abstract
Expanding the US Food and Drug Administration-approved indications for immune checkpoint inhibitors in patients with cancer has resulted in therapeutic success and immune-related adverse events (irAEs). Neurologic irAEs (irAE-Ns) have an incidence of 1%-12% and a high fatality rate relative to other irAEs. Lack of standardized disease definitions and accurate phenotyping leads to syndrome misclassification and impedes development of evidence-based treatments and translational research. The objective of this study was to develop consensus guidance for an approach to irAE-Ns including disease definitions and severity grading. A working group of four neurologists drafted irAE-N consensus guidance and definitions, which were reviewed by the multidisciplinary Neuro irAE Disease Definition Panel including oncologists and irAE experts. A modified Delphi consensus process was used, with two rounds of anonymous ratings by panelists and two meetings to discuss areas of controversy. Panelists rated content for usability, appropriateness and accuracy on 9-point scales in electronic surveys and provided free text comments. Aggregated survey responses were incorporated into revised definitions. Consensus was based on numeric ratings using the RAND/University of California Los Angeles (UCLA) Appropriateness Method with prespecified definitions. 27 panelists from 15 academic medical centers voted on a total of 53 rating scales (6 general guidance, 24 central and 18 peripheral nervous system disease definition components, 3 severity criteria and 2 clinical trial adjudication statements); of these, 77% (41/53) received first round consensus. After revisions, all items received second round consensus. Consensus definitions were achieved for seven core disorders: irMeningitis, irEncephalitis, irDemyelinating disease, irVasculitis, irNeuropathy, irNeuromuscular junction disorders and irMyopathy. For each disorder, six descriptors of diagnostic components are used: disease subtype, diagnostic certainty, severity, autoantibody association, exacerbation of pre-existing disease or de novo presentation, and presence or absence of concurrent irAE(s). These disease definitions standardize irAE-N classification. Diagnostic certainty is not always directly linked to certainty to treat as an irAE-N (ie, one might treat events in the probable or possible category). Given consensus on accuracy and usability from a representative panel group, we anticipate that the definitions will be used broadly across clinical and research settings.
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Affiliation(s)
- Amanda C Guidon
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Leeann B Burton
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bart K Chwalisz
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James Hillis
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Anthony A Amato
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Allison Betof Warner
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Priscilla K Brastianos
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tracey A Cho
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake CIty, UT, USA
| | - Justine V Cohen
- Division of Oncology, Department of Medicine, University of Pennsylvania, PA, USA
| | - Jorg Dietrich
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher T Doughty
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Divyanshu Dubey
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Jeffrey T Guptill
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Division of Neuromuscular Medicine, Duke University, Durham, NC, USA
| | - Douglas B Johnson
- Division of Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vern C Juel
- Division of Neuromuscular Medicine, Duke University, Durham, NC, USA
| | - Robert Kadish
- Department of Neurology, University of Utah, Salt Lake CIty, UT, USA
| | - Noah Kolb
- Division of Neuromuscular Medicine, Department of Neurology, University of Vermont, Burlington, VT, USA
| | - Nicole R LeBoeuf
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Jenny Linnoila
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew L Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Maria Martinez-Lage
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuropathology, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan J Mooradian
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jarushka Naidoo
- Medical Oncology, Department of Medicine, Beaumont Hospital Dublin and RCSI University of Health Sciences, Dublin, Ireland
- Upper Aerodigestive Division, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center/Johns Hopkins University, Baltimore, MD, USA
| | - Tomas G Neilan
- Harvard Medical School, Boston, Massachusetts, USA
- Cardio-oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David A Reardon
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Neuro-oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Krista M Rubin
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bianca D Santomasso
- Department of Neurology, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy Wang
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Karin Woodman
- Section of Cancer Neurology, Department of Neuro-Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Leyre Zubiri
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kerry L Reynolds
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Mandel-Brehm C, Dubey D, Kryzer TJ, O'Donovan BD, Tran B, Vazquez SE, Sample HA, Zorn KC, Khan LM, Bledsoe IO, McKeon A, Pleasure SJ, Lennon VA, DeRisi JL, Wilson MR, Pittock SJ. Kelch-like Protein 11 Antibodies in Seminoma-Associated Paraneoplastic Encephalitis. N Engl J Med 2019; 381:47-54. [PMID: 31269365 PMCID: PMC6800027 DOI: 10.1056/nejmoa1816721] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A 37-year-old man with a history of seminoma presented with vertigo, ataxia, and diplopia. An autoantibody specific for kelch-like protein 11 (KLHL11) was identified with the use of programmable phage display. Immunoassays were used to identify KLHL11 IgG in 12 other men with similar neurologic features and testicular disease. Immunostaining of the patient's IgG on mouse brain tissue showed sparse but distinctive points of staining in multiple brain regions, with enrichment in perivascular and perimeningeal tissues. The onset of the neurologic syndrome preceded the diagnosis of seminoma in 9 of the 13 patients. An age-adjusted estimate of the prevalence of autoimmune KLHL11 encephalitis in Olmsted County, Minnesota, was 2.79 cases per 100,000 men. (Funded by the Rochester Epidemiology Project and others.).
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Affiliation(s)
- Caleigh Mandel-Brehm
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Divyanshu Dubey
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Thomas J Kryzer
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Brian D O'Donovan
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Baouyen Tran
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Sara E Vazquez
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Hannah A Sample
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Kelsey C Zorn
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Lillian M Khan
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Ian O Bledsoe
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Andrew McKeon
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Samuel J Pleasure
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Vanda A Lennon
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Joseph L DeRisi
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Michael R Wilson
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
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