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Farina A, Villagrán-García M, Fourier A, Pinto AL, Chorfa F, Timestit N, Alberto T, Aupy J, Benaiteau M, Birzu C, Campetella L, Cotton F, Dalle S, Delaruelle CF, Dumez P, Germi R, Le Maréchal M, Maillet D, Marignier R, Pegat A, Psimaras D, Rafiq M, Picard G, Desestret V, Quadrio I, Honnorat J, Joubert B. Diagnostic and prognostic biomarkers in immune checkpoint inhibitor-related encephalitis: a retrospective cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 44:101011. [PMID: 39170102 PMCID: PMC11338149 DOI: 10.1016/j.lanepe.2024.101011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/06/2024] [Accepted: 07/11/2024] [Indexed: 08/23/2024]
Abstract
Background Immune checkpoint inhibitor-related encephalitis (ICI-encephalitis) is not well characterised and diagnostic and prognostic biomarkers are lacking. We aimed to comprehensively characterise ICI-encephalitis and identify diagnostic biomarkers and outcome predictors. Methods This retrospective observational study included all patients with ICI-encephalitis studied in the French Reference Centre on Paraneoplastic Neurological Syndromes (PNS) and Autoimmune Encephalitis (2015-2023). ICI encephalitis was considered definite in case of inflammatory findings at paraclinical tests and/or well-characterised neural antibodies. Predictors of immune-related adverse event (irAE) treatment response, defined as a Common Terminology Criteria for Adverse Events v5.0 grade < 3 at any time after therapeutic intervention, were assessed by logistic regression analysis, and predictors of mortality by Cox regression analysis. Neurofilament light chain (NfL) was measured by enzyme-linked immunosorbent assay. Findings Sixty-seven patients with definite encephalitis were identified (median age, 69 years; 66% male). A focal syndrome was observed in 43/67 patients (64%; limbic encephalitis, cerebellar ataxia, and/or brainstem encephalitis), while 24/67 (36%) had meningoencephalitis, a non-focal syndrome with altered mental status (22/24 patients, 92%) and pleocytosis (24/24 patients, 100%). Patients with focal encephalitis more frequently had abnormal brain MRI (26/42, 62% versus 8/24, 33%, p = 0.025), PNS-related antibodies (36/43, 84% versus 1/24, 4%, p < 0.001), and neuroendocrine cancers (22/43, 51% versus 1/24, 4%; p < 0.001) than patients with meningoencephalitis. Focal encephalitis patients had a lower rate of irAE treatment response (7/39, 18%) and higher mortality (27/43, 63%) compared to meningoencephalitis patients (12/22, 77% and 5/24, 21%, respectively, p < 0.001 each). PNS-related antibodies were associated with less irAE treatment response, independently of age, sex, and baseline severity (adjusted OR 0.05; 95%CI [0.01; 0.19]; p < 0.001) as well as higher mortality, independently of age and cancer type (adjusted HR 5.07; 95% CI [2.12; 12.12]; p < 0.001). Serum NfL discriminated patients with definite ICI-encephalitis (n = 27) from cancer-matched controls (n = 16; optimal cut-off >273.5 pg/mL, sensitivity 81%, specificity 88%, AUC 0.87, 95% CI [0.76; 0.98]) and irAE treatment responders (n = 10) from non-responders (n = 17, optimal cut-off >645 pg/mL, sensitivity 90%, specificity 65%; AUC 0.75, 95% CI [0.55; 0.94]). Interpretation ICI-encephalitis corresponds to a set of clinically-recognisable syndromes. Patients with focal encephalitis, PNS-related antibodies, and/or higher serum NfL have low irAE treatment response rates. Research is needed on the underlying immunopathogenesis to foster therapeutic innovations. Funding Agence Nationale de la Recherche.
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Affiliation(s)
- Antonio Farina
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Macarena Villagrán-García
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Anthony Fourier
- Lyon Neuroscience Research Center (CRNL), Université de Lyon, CNRS, INSERM, Lyon, France
| | - Anne-Laurie Pinto
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Fatima Chorfa
- Service de Biostatistique et Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Noémie Timestit
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Tifanie Alberto
- Department of Neurology, CRC SEP, Centre Hospitalier of Lille, Lille, France
| | - Jérôme Aupy
- Department of Clinical Neurosciences, Centre Hospitalier of Bordeaux, Bordeaux, France
- CNRS, IMN, UMR 5293, University of Bordeaux, Bordeaux, France
| | - Marie Benaiteau
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Cristina Birzu
- AP-HP, Hospital Group Pitié-Salpêtrière, Neuro-oncology Department Paris, France
- Inserm U1127, CNRS, Paris Brain Institute, Institut du Cerveau (ICM), Paris, France
| | - Lucia Campetella
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - François Cotton
- Radiology Department, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Stéphane Dalle
- Deparment of Dermatology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
| | - Clara Fontaine Delaruelle
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
- Department of Pneumology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Pauline Dumez
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Rafaele Germi
- Virology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Marion Le Maréchal
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Denis Maillet
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
- Department of Medical Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hospices Civils de Lyon, Lyon, France
| | - Antoine Pegat
- Service ENMG et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, INMG, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
| | - Dimitri Psimaras
- AP-HP, Hospital Group Pitié-Salpêtrière, Neuro-oncology Department Paris, France
- Inserm U1127, CNRS, Paris Brain Institute, Institut du Cerveau (ICM), Paris, France
| | - Marie Rafiq
- Department of Cognitive Neurology, Epilepsy and Movement Disorders, Toulouse Purpan University Hospital Center, Toulouse, France
| | - Géraldine Picard
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Virginie Desestret
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Isabelle Quadrio
- Lyon Neuroscience Research Center (CRNL), Université de Lyon, CNRS, INSERM, Lyon, France
| | - Jérôme Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
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Zekeridou A. Paraneoplastic Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1021-1051. [PMID: 39088287 DOI: 10.1212/con.0000000000001449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE This article reviews the clinical presentations, neural antibody associations, and oncologic accompaniments of paraneoplastic neurologic syndromes and neurologic autoimmunity in the context of immune checkpoint inhibitor (ICI) cancer immunotherapy. LATEST DEVELOPMENTS Neural antibody discovery has improved the diagnosis of paraneoplastic neurologic syndromes. Neural antibodies also delineate the underlying disease pathophysiology and thus inform outcomes and treatments. Neural antibodies specific for extracellular proteins have pathogenic potential, whereas antibodies specific for intracellular targets are biomarkers of a cytotoxic T-cell immune response. A recent update in paraneoplastic neurologic syndrome criteria suggests high- and intermediate-risk phenotypes as well as neural antibodies to improve diagnostic accuracy in patients with paraneoplastic neurologic syndromes; a score was created based on this categorization. The introduction of ICI cancer immunotherapy has led to an increase in cancer-related neurologic autoimmunity with distinct clinical phenotypes. ESSENTIAL POINTS Paraneoplastic neurologic syndromes reflect an ongoing immunologic response to cancer mediated by effector T cells or antibodies. Paraneoplastic neurologic syndromes can present with manifestations at any level of the neuraxis, and neural antibodies aid diagnosis, focus cancer screening, and inform prognosis and therapy. In patients with high clinical suspicion of a paraneoplastic neurologic syndrome, cancer screening and treatment should be undertaken, regardless of the presence of a neural antibody. ICI therapy has led to immune-mediated neurologic complications. Recognition and treatment lead to improved outcomes.
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Stavropoulou De Lorenzo S, Andravizou A, Alexopoulos H, Michailidou I, Bokas A, Kesidou E, Boziki MK, Parissis D, Bakirtzis C, Grigoriadis N. Neurological Immune-Related Adverse Events Induced by Immune Checkpoint Inhibitors. Biomedicines 2024; 12:1319. [PMID: 38927526 PMCID: PMC11202292 DOI: 10.3390/biomedicines12061319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
The use of immune checkpoint inhibitors (ICIs) for the treatment of various advanced and aggressive types of malignancy has significantly increased both survival and long-term remission rates. ICIs block crucial inhibitory pathways of the immune system, in order to trigger an aggravated immune response against the tumor. However, this enhanced immune activation leads to the development of numerous immune-related adverse events (irAEs), which may affect any system. Although severe neurological irAEs are relatively rare, they carry a high disability burden, and they can be potentially life-threatening. Therefore, clinicians must be alert and act promptly when individuals receiving ICIs present with new-onset neurological symptoms. In this narrative review, we have collected all the currently available data regarding the epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of post-ICI neurological irAEs. This review aims to raise physicians' awareness, enrich their knowledge regarding disease pathogenesis, and guide them through the diagnosis and management of post-ICI neurological irAEs.
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Affiliation(s)
- Sotiria Stavropoulou De Lorenzo
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Athina Andravizou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Harry Alexopoulos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, University Campus, 15784 Athens, Greece;
| | - Iliana Michailidou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Alexandros Bokas
- Department of Medical Oncology, Theageneio Cancer Hospital, 54639 Thessaloniki, Greece;
| | - Evangelia Kesidou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Marina-Kleopatra Boziki
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Dimitrios Parissis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Christos Bakirtzis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Nikolaos Grigoriadis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
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Farina A, Villagrán-García M, Vogrig A, Joubert B. Central nervous system adverse events of immune checkpoint inhibitors. Curr Opin Neurol 2024; 37:345-352. [PMID: 38483130 DOI: 10.1097/wco.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICI) may trigger immune-related adverse events which rarely affect the central nervous system (CNS-irAEs). Over the past few years, cumulative data have led to the characterization of well defined syndromes with distinct cancer and antibody associations as well as different outcomes. RECENT FINDINGS The most frequent CNS-irAE is encephalitis, which includes three main groups: meningoencephalitis, a nonfocal syndrome usually responsive to corticosteroids; limbic encephalitis, associated with high-risk paraneoplastic neurological syndromes (PNS) antibodies (e.g. anti-Hu, anti-Ma2) and neuroendocrine cancers, characterized by poor treatment response and outcomes; and cerebellar ataxia, with variable outcomes (worse when high-risk PNS antibodies are detected). Additionally, a diffuse encephalopathy without inflammatory findings, with poor response to corticosteroids and high mortality has been described. The spectrum of CNS-irAEs also includes meningitis, myelitis, and rarer presentations. A subset of CNS-irAEs (i.e. limbic encephalitis and/or rapidly progressive cerebellar ataxia) is undistinguishable from ICI-naïve PNS. SUMMARY The clinical and outcomes diversity of CNS-irAEs suggests different pathogenic mechanisms, which need to be understood to establish more effective and specific treatment modalities. It is crucial to identify biomarkers able to predict which patients will experience severe CNS-irAEs, to anticipate their diagnosis, and to predict long-term outcomes.
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Affiliation(s)
- Antonio Farina
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Macarena Villagrán-García
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- Department of Medicine (DMED), University of Udine
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Bastien Joubert
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
- Department of Neurology, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
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Mangioris G, Halfdanarson TR, Lennon VA, Chang BK, Dubey D, Dyck PJB, Flanagan EP, McKeon A, Mills JR, Pittock SJ, Zekeridou A. Neurological autoimmunity in patients with non-pulmonary neuroendocrine neoplasms: clinical manifestations and neural autoantibody profiles. Eur J Neurol 2024; 31:e16273. [PMID: 38466015 PMCID: PMC11235830 DOI: 10.1111/ene.16273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND AND PURPOSE Paraneoplastic neurological autoimmunity is well described with small-cell lung cancer, but information is limited for other neuroendocrine neoplasms (NENs). METHODS Adult patients with histopathologically confirmed non-pulmonary NENs, neurological autoimmunity within 5 years of NEN diagnosis, and neural antibody testing performed at the Mayo Clinic Neuroimmunology Laboratory (January 2008 to March 2023) were retrospectively identified. Control sera were available from patients with NENs without neurological autoimmunity (116). RESULTS Thirty-four patients were identified (median age 68 years, range 31-87). The most common primary tumor sites were pancreas (nine), skin (Merkel cell, eight), small bowel/duodenum (seven), and unknown (seven). Five patients received immune checkpoint inhibitor (ICI) therapy before symptom onset; symptoms preceded cancer diagnosis in 62.1% of non-ICI-treated patients. The most frequent neurological phenotypes (non-ICI-treated) were movement disorders (12; cerebellar ataxia in 10), dysautonomia (six), peripheral neuropathy (eight), encephalitis (four), and neuromuscular junction disorders (four). Neural antibodies were detected in 55.9% of patients studied (most common specificities: P/Q-type voltage-gated calcium channel [seven], muscle-type acetylcholine receptor [three], anti-neuronal nuclear antibody type 1 [three], and neuronal intermediate filaments [two]), but in only 6.9% of controls. Amongst patients receiving cancer or immunosuppressive therapy, 51.6% had partial or complete recovery. Outcomes were unfavorable in 48.3% (non-ICI-treated) and neural autoantibody positivity was associated with poor neurological outcome. DISCUSSION Neurological autoimmunity associated with non-pulmonary NENs is often multifocal and can be treatment responsive, underscoring the importance of rapid recognition and early treatment.
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Affiliation(s)
- Georgios Mangioris
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | | | - Vanda A. Lennon
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Department of ImmunologyMayo ClinicRochesterMinnesotaUSA
| | | | - Divyanshu Dubey
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
| | | | - Eoin P. Flanagan
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
| | - Andrew McKeon
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
| | - John R. Mills
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Sean J. Pittock
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
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Vaghi G, Vegezzi E, Bini P, Gastaldi M, Diamanti L, Marchioni E, Colnaghi S. A Case of Anti-Ma2 Encephalitis Presenting with Pendular Torsional Nystagmus. CEREBELLUM (LONDON, ENGLAND) 2024; 23:1249-1253. [PMID: 37848701 PMCID: PMC11102397 DOI: 10.1007/s12311-023-01601-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 10/19/2023]
Abstract
Antibodies against the neuronal protein Ma2 have been reported in a peculiar form of paraneoplastic encephalitis with prominent involvement of the limbic, brainstem, and diencephalic structures and usually associated with germ cell testicular, lung, or breast cancer. The diagnosis is frequently challenged by atypical clinical manifestations including parkinsonism, sleep disturbances, hypothalamic-pituitary dysfunctions, and motor neuron-like syndrome. In recent years, the advent of monoclonal antibodies targeting immune checkpoints has deeply changed the treatment of different tumors, especially melanoma and lung cancer. However, given their nature, an increasing number of neurological immune-related adverse events, including ocular motor abnormalities, have been described. Here, we report a woman with advanced non-small cell lung cancer treated with anti-PD-L1 durvalumab, presenting with an isolated pendular torsional nystagmus, in association with anti-Ma2 antibodies. This peculiar case widens our knowledge on the clinical presentation of anti-Ma2 encephalitis associated with checkpoint inhibitors.
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Affiliation(s)
- Gloria Vaghi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy.
| | - Elisa Vegezzi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Paola Bini
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy
- Neuroimmunology Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Luca Diamanti
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Enrico Marchioni
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Silvia Colnaghi
- Neurology Unit, Dipartimento Funzionale Sperimentale Interaziendale di Neuroscienze, ASST, Pavia, Italy
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Aboseif A, Vorasoot N, Pinto MV, Guo Y, Hasan S, Zekeridou A, Chen JJ, Dubey D. Immune Checkpoint Inhibitor-Associated Kelch-Like Protein-11 IgG Brainstem Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200218. [PMID: 38484218 DOI: 10.1212/nxi.0000000000200218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/19/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES Kelch-like protein-11 (KLHL11)-IgG is associated with rhombencephalitis and seminoma. It has not previously been described as a neurologic immune checkpoint inhibitor (ICI)-related adverse event (nirAE) or in association with esophageal adenocarcinoma. METHODS We describe a 61-year-old man with metastatic esophageal adenocarcinoma treated with folinic acid, fluorouracil, oxaliplatin (FOLFOX), and nivolumab, who subsequently developed diplopia, vertigo, and progressive gait ataxia after 8 weeks of treatment. RESULTS Owing to a concern for ICI-associated myasthenia gravis, nivolumab was held and he was treated with prednisone and pyridostigmine. EMG showed no neuromuscular junction dysfunction, and acetylcholine-receptor antibodies were negative. Brain MRI was unrevealing. Murine brain tissue immunofluorescence assay revealed KLHL11-IgG in both serum and CSF, confirmed by cell-based assay. Tumor histopathology demonstrated poorly differentiated, highly proliferative adenocarcinoma with increased mitotic figures and cytoplasmic KLHL11 immunoreactivity. He was initiated on 6 months of cyclophosphamide in addition to FOLFOX for post-ICI-associated KLHL11-IgG rhombencephalitis. DISCUSSION We report KLHL11-IgG rhombencephalitis associated with poorly differentiated esophageal cancer as a novel nirAE. Tumor staining revealed KLHL11 immunoreactivity, supporting a cancer-antigen-driven ICI-associated paraneoplastic syndrome. Recognition of novel nirAEs can expedite treatment and potentially prevent progressive neurologic disability.
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Affiliation(s)
- Albert Aboseif
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Nisa Vorasoot
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Marcus V Pinto
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Yong Guo
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Shemonti Hasan
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Anastasia Zekeridou
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - John J Chen
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Divyanshu Dubey
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
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8
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Zammit F, Seront E. Neurological Adverse Events Related to Immune Checkpoint Inhibitors: A Practical Review. Pharmaceuticals (Basel) 2024; 17:501. [PMID: 38675461 PMCID: PMC11053462 DOI: 10.3390/ph17040501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The increasing use of immune checkpoint inhibitors (ICI) in cancer therapy has brought attention to their associated neurotoxicities, termed neurological immune-related adverse events (n-irAEs). Despite their relatively rare incidence, n-irAEs pose a significant risk, potentially leading to severe, long-lasting disabilities or even fatal outcomes. This narrative review aims to provide a comprehensive overview of n-irAEs, focusing on their recognition and management. The review addresses a spectrum of n-irAEs, encompassing myositis, myasthenia gravis, various neuropathies, and central nervous system complications, such as encephalitis, meningitis, and demyelinating diseases. The key features of n-irAEs are emphasized in this review, including their early onset after initiation of ICIs, potential association with non-neurological irAEs and/or concurrent oncological response, the significance of ruling out other etiologies, and the expected improvement upon discontinuation of ICIs and/or immunosuppression. Furthermore, this review delves into considerations for ICI re-challenge and the intricate nature of n-irAEs within the context of pre-existing autoimmune and paraneoplastic syndromes. It underscores the importance of a multidisciplinary approach to diagnosis and treatment, highlighting the pivotal role of severity grading in guiding treatment decisions.
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Affiliation(s)
| | - Emmanuel Seront
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
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9
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Casagrande S, Sopetto GB, Bertalot G, Bortolotti R, Racanelli V, Caffo O, Giometto B, Berti A, Veccia A. Immune-Related Adverse Events Due to Cancer Immunotherapy: Immune Mechanisms and Clinical Manifestations. Cancers (Basel) 2024; 16:1440. [PMID: 38611115 PMCID: PMC11011060 DOI: 10.3390/cancers16071440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
The landscape of cancer treatment has undergone a significant transformation with the introduction of Immune Checkpoint Inhibitors (ICIs). Patients undergoing these treatments often report prolonged clinical and radiological responses, albeit with a potential risk of developing immune-related adverse events (irAEs). Here, we reviewed and discussed the mechanisms of action of ICIs and their pivotal role in regulating the immune system to enhance the anti-tumor immune response. We scrutinized the intricate pathogenic mechanisms responsible for irAEs, arising from the evasion of self-tolerance checkpoints due to drug-induced immune modulation. We also summarized the main clinical manifestations due to irAEs categorized by organ types, detailing their incidence and associated risk factors. The occurrence of irAEs is more frequent when ICIs are combined; with neurological, cardiovascular, hematological, and rheumatic irAEs more commonly linked to PD1/PD-L1 inhibitors and cutaneous and gastrointestinal irAEs more prevalent with CTLA4 inhibitors. Due to the often-nonspecific signs and symptoms, the diagnosis of irAEs (especially for those rare ones) can be challenging. The differential with primary autoimmune disorders becomes sometimes intricate, given the clinical and pathophysiological similarities. In conclusion, considering the escalating use of ICIs, this area of research necessitates additional clinical studies and practical insights, especially the development of biomarkers for predicting immune toxicities. In addition, there is a need for heightened education for both clinicians and patients to enhance understanding and awareness.
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Affiliation(s)
- Silvia Casagrande
- Unit of Neurology, Rovereto Hospital, Azienda Provinciale per i Servizi Sanitari-APSS, 38122 Trento, Italy; (S.C.); (B.G.)
| | - Giulia Boscato Sopetto
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38122 Trento, Italy; (G.B.S.); (G.B.); (V.R.)
| | - Giovanni Bertalot
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38122 Trento, Italy; (G.B.S.); (G.B.); (V.R.)
- Center for Medical Sciences (CISMed), University of Trento, 38122 Trento, Italy
- Multizonal Unit of Pathology, APSS, 38122 Trento, Italy
| | - Roberto Bortolotti
- Unit of Rheumatology, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy;
| | - Vito Racanelli
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38122 Trento, Italy; (G.B.S.); (G.B.); (V.R.)
- Center for Medical Sciences (CISMed), University of Trento, 38122 Trento, Italy
- Unit of Internal Medicine, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy
| | - Orazio Caffo
- Unit of Oncology, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy; (O.C.); (A.V.)
| | - Bruno Giometto
- Unit of Neurology, Rovereto Hospital, Azienda Provinciale per i Servizi Sanitari-APSS, 38122 Trento, Italy; (S.C.); (B.G.)
- Center for Medical Sciences (CISMed), University of Trento, 38122 Trento, Italy
- Department of Psychology and Cognitive Sciences (DIPSCO), University of Trento, 38122 Trento, Italy
| | - Alvise Berti
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38122 Trento, Italy; (G.B.S.); (G.B.); (V.R.)
- Center for Medical Sciences (CISMed), University of Trento, 38122 Trento, Italy
- Unit of Rheumatology, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy;
| | - Antonello Veccia
- Unit of Oncology, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy; (O.C.); (A.V.)
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10
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Manto M, Hadjivassiliou M, Baizabal-Carvallo JF, Hampe CS, Honnorat J, Joubert B, Mitoma H, Muñiz-Castrillo S, Shaikh AG, Vogrig A. Consensus Paper: Latent Autoimmune Cerebellar Ataxia (LACA). CEREBELLUM (LONDON, ENGLAND) 2024; 23:838-855. [PMID: 36991252 PMCID: PMC10060034 DOI: 10.1007/s12311-023-01550-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 06/01/2023]
Abstract
Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies. Patients with IMCAs develop cerebellar symptoms, characterized mainly by gait ataxia, showing an acute or subacute clinical course. We present a novel concept of latent autoimmune cerebellar ataxia (LACA), analogous to latent autoimmune diabetes in adults (LADA). LADA is a slowly progressive form of autoimmune diabetes where patients are often initially diagnosed with type 2 diabetes. The sole biomarker (serum anti-GAD antibody) is not always present or can fluctuate. However, the disease progresses to pancreatic beta-cell failure and insulin dependency within about 5 years. Due to the unclear autoimmune profile, clinicians often struggle to reach an early diagnosis during the period when insulin production is not severely compromised. LACA is also characterized by a slowly progressive course, lack of obvious autoimmune background, and difficulties in reaching a diagnosis in the absence of clear markers for IMCAs. The authors discuss two aspects of LACA: (1) the not manifestly evident autoimmunity and (2) the prodromal stage of IMCA's characterized by a period of partial neuronal dysfunction where non-specific symptoms may occur. In order to achieve an early intervention and prevent cell death in the cerebellum, identification of the time-window before irreversible neuronal loss is critical. LACA occurs during this time-window when possible preservation of neural plasticity exists. Efforts should be devoted to the early identification of biological, neurophysiological, neuropsychological, morphological (brain morphometry), and multimodal biomarkers allowing early diagnosis and therapeutic intervention and to avoid irreversible neuronal loss.
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Affiliation(s)
- Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, Charleroi, Belgium
- Service des Neurosciences, University of Mons, Mons, Belgium
| | | | | | | | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan.
| | | | - Aasef G Shaikh
- Louis Stokes Cleveland VA Medical Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alberto Vogrig
- Clinical Neurology, Udine University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
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11
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Otis SU, Banna GL, Maniam A. The association between paraneoplastic neurological syndromes (PNS) and urothelial carcinoma - A review of the literature. Crit Rev Oncol Hematol 2024; 196:104314. [PMID: 38447785 DOI: 10.1016/j.critrevonc.2024.104314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 02/10/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024] Open
Abstract
Paraneoplastic neurological syndromes (PNS) are rare neurological disorders arising from malignancy-triggered autoimmunity, yet their association with urothelial carcinoma remains unclear. This systematic review intends to explore any connection, alongside patient/clinical features and management. A literature search identified 25 cases of bladder and upper tract carcinoma linked to PNS. Overall, while infrequent, a meaningful association between PNS and urothelial carcinoma was found in that 84% of cases met a 'possible'-or-'higher-likelihood' PNS diagnosis. Most cases presented with high-risk PNS phenotypes, predominantly cerebellar syndromes and encephalomyelitis/sensory neuronopathy, ∼17 months within cancer diagnosis/recurrence. Review findings suggest a female preponderance in suspected PNS despite higher male incidence of urothelial cancer. Main treatments consisted of surgery alongside chemotherapy or immunotherapeutics (IVIG and/or corticosteroids), which improved symptoms for a slight majority (60%). Ultimately, while common PNS-associated neoplasms should always first be excluded in suspected PNS, in the absence of alternative causes, urothelial carcinomas do merit clinical consideration.
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Affiliation(s)
- Sarafina Urenna Otis
- Medical Sciences Division, University of Oxford, John Radcliffe Hospital, Oxford, England OX3 9DU, UK
| | - Giuseppe Luigi Banna
- Portsmouth Hospitals University NHS Trust, Portsmouth, England PO6 3LY, UK; Faculty of Science and Health, School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, England PO1 2UP, UK
| | - Akash Maniam
- Portsmouth Hospitals University NHS Trust, Portsmouth, England PO6 3LY, UK; Caribbean Cancer Research Institute, Chanka Trace El Socorro South, Trinidad and Tobago.
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12
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Vogrig A, Tartaglia S, Dentoni M, Fabris M, Bax F, Belluzzo M, Verriello L, Bagatto D, Gastaldi M, Tocco P, Zoccarato M, Zuliani L, Pilotto A, Padovani A, Villagrán-García M, Davy V, Gigli GL, Honnorat J, Valente M. Central nervous system immune-related disorders after SARS-CoV-2 vaccination: a multicenter study. Front Immunol 2024; 15:1344184. [PMID: 38375477 PMCID: PMC10876052 DOI: 10.3389/fimmu.2024.1344184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/09/2024] [Indexed: 02/21/2024] Open
Abstract
Background COVID-19 vaccines have been approved due to their excellent safety and efficacy data and their use has also permitted to reduce neurological complications of SARS-CoV-2. However, clinical trials were underpowered to detect rare adverse events. Herein, the aim was to characterize the clinical spectrum and immunological features of central nervous system (CNS) immune-related events following SARS-CoV-2 vaccination. Methods Multicenter, retrospective, cohort study (December 1, 2020-April 30, 2022). Inclusion criteria were (1) de novo CNS disorders developing after SARS-CoV-2 vaccination (probable causal relationship as per 2021 Butler criteria) (2); evidence for an immune-mediated etiology, as per (i) 2016 Graus criteria for autoimmune encephalitis (AE); (ii) 2015 Wingerchuk criteria for neuromyelitis optica spectrum disorders; (iii) criteria for myelitis. Results Nineteen patients were included from 7 tertiary referral hospitals across Italy and France (one of them being a national referral center for AE), over almost 1 year and half of vaccination campaign. Vaccines administered were mRNA-based (63%) and adenovirus-vectored (37%). The median time between vaccination and symptoms onset was 14 days (range: 2-41 days). CSF was inflammatory in 74%; autoantibodies were detected in 5%. CSF cytokine analysis (n=3) revealed increased CXCL-10 (IP-10), suggesting robust T-cell activation. The patients had AE (58%), myelitis (21%), acute disseminated encephalomyelitis (ADEM) (16%), and brainstem encephalitis (5%). All patients but 2 received immunomodulatory treatment. At last follow-up (median 130 days; range: 32-540), only one patient (5%) had a mRS>2. Conclusion CNS adverse events of COVID-19 vaccination appear to be very rare even at reference centers and consist mostly of antibody-negative AE, myelitis, and ADEM developing approximately 2 weeks after vaccination. Most patients improve following immunomodulatory treatment.
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Affiliation(s)
- Alberto Vogrig
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Sara Tartaglia
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Marta Dentoni
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Martina Fabris
- Institute of Clinical Pathology, Department of Laboratory Medicine, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Francesco Bax
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Marco Belluzzo
- Neurology Unit, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Lorenzo Verriello
- Neurology Unit, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Daniele Bagatto
- Department of Diagnostic Imaging, Unit of Neuroradiology, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Pierluigi Tocco
- Neurology and Stroke Unit, “Spirito Santo” Hospital of Pescara, Pescara, Italy
| | - Marco Zoccarato
- UOC Neurologia O.S.A. - Azienda Ospedale Università di Padova, Padua, Italy
| | - Luigi Zuliani
- Neurology Unit, AULSS8 Berica, San Bortolo Hospital, Vicenza, Italy
| | - Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Neurology Unit, Department of Continuity of Care and Frailty, ASST Spedali Civili Brescia University Hospital, Brescia, Italy
- Laboratory of Digital Neurology and Biosensors, University of Brescia, Brescia, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Neurology Unit, Department of Continuity of Care and Frailty, ASST Spedali Civili Brescia University Hospital, Brescia, Italy
- Laboratory of Digital Neurology and Biosensors, University of Brescia, Brescia, Italy
| | - Macarena Villagrán-García
- French Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Vincent Davy
- Department of Neurology, Hôpital Pitié Salpétrière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Gian Luigi Gigli
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Jérôme Honnorat
- French Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Mariarosaria Valente
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
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13
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Müller-Jensen L, Schulz AR, Mei HE, Mohr R, Ulrich C, Knape P, Frost N, Frischbutter S, Kunkel D, Schinke C, Ginesta Roque L, Maierhof SK, Nickel FT, Heinzerling L, Endres M, Boehmerle W, Huehnchen P, Knauss S. Immune signatures of checkpoint inhibitor-induced autoimmunity-A focus on neurotoxicity. Neuro Oncol 2024; 26:279-294. [PMID: 37823709 PMCID: PMC10836772 DOI: 10.1093/neuonc/noad198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Neurologic immune-related adverse events (irAE-n) are rare but severe toxicities of immune checkpoint inhibitor (ICI) treatment. To overcome diagnostic and therapeutic challenges, a better mechanistic understanding of irAE-n is paramount. METHODS In this observational cohort study, we collected serum and peripheral blood samples from 34 consecutive cancer patients with irAE-n (during acute illness) and 49 cancer control patients without irAE-n (pre- and on-ICI treatment, n = 44 without high-grade irAEs, n = 5 with high-grade nonneurologic irAEs). Patients received either anti-programmed cell death protein (PD)-1 or anti-PD ligand-1 monotherapy or anti-PD-1/anti-cytotoxic T-lymphocyte-associated protein-4 combination therapy. Most common cancers were melanoma, lung cancer, and hepatocellular carcinoma. Peripheral blood immune profiling was performed using 48-marker single-cell mass cytometry and a multiplex cytokine assay. RESULTS During acute illness, patients with irAE-n presented higher frequencies of cluster of differentiation (CD)8+ effector memory type (EM-)1 and central memory (CM) T cells compared to controls without irAEs. Multiorgan immunotoxicities (neurologic + nonneurologic) were associated with higher CD8+ EM1 T cell counts. While there were no B cell changes in the overall cohort, we detected a marked decrease of IgD- CD11c+ CD21low and IgD- CD24+ CD21high B cells in a subgroup of patients with autoantibody-positive irAE-n. We further identified signatures indicative of enhanced chemotaxis and inflammation in irAE-n patients and discovered C-X-C motif chemokine ligand (CXCL)10 as a promising marker to diagnose high-grade immunotoxicities such as irAE-n. CONCLUSIONS We demonstrate profound and partly subgroup-specific immune cell dysregulation in irAE-n patients, which may guide future biomarker development and targeted treatment approaches.
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Affiliation(s)
- Leonie Müller-Jensen
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Axel R Schulz
- Mass Cytometry Laboratory, German Rheumatism Research Center (DRFZ), A Leibniz Institute, Berlin, Germany
| | - Henrik E Mei
- Mass Cytometry Laboratory, German Rheumatism Research Center (DRFZ), A Leibniz Institute, Berlin, Germany
| | - Raphael Mohr
- Department of Hepatology and Gastroenterology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Claas Ulrich
- Department of Dermatology, Venerology, and Allergology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Collegium Medicum Berlin GmbH, Berlin, Germany
| | - Philipp Knape
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Nikolaj Frost
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Frischbutter
- Institute of Allergology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Desiree Kunkel
- Flow and Mass Cytometry Core Facility, Berlin Institute of Health at Charité – Univeritätsmedizin Berlin, Berlin, Germany
| | - Christian Schinke
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Lorena Ginesta Roque
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Smilla K Maierhof
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin (ECN) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Florian T Nickel
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, München, Germany
- Department of Dermatology and Allergy, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Wolfgang Boehmerle
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Petra Huehnchen
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Samuel Knauss
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
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14
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McCombe JA, Sechi E, Zekeridou A. Neurologic manifestations of autoimmunity with immune checkpoint inhibitors. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:449-465. [PMID: 38494296 DOI: 10.1016/b978-0-12-823912-4.00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Immune checkpoint inhibitors (ICIs) are cancer immunotherapies that enhance the body's own immune system to treat cancer. ICI treatment, however, can cause immune-related adverse events (irAEs) that can affect any organ, resulting in significant morbidity and mortality. Neurologic irAEs (nirAEs) are rare and can affect the peripheral nervous system more commonly than the central nervous system. Treatment is dependent on the severity of the neurologic manifestations and often includs discontinuation of the ICI and initiation of steroid therapy as the first line; other treatments have also been used. NirAEs and cardiac irAEs have higher fatality rates underlying the importance of early recognition and appropriate management. This chapter reviews the clinical manifestations of neurologic immune-related adverse events associated with ICI treatment as well as diagnostic and therapeutic modalities.
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Affiliation(s)
- Jennifer A McCombe
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States.
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15
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Farina A, Villagrán-García M, Vogrig A, Zekeridou A, Muñiz-Castrillo S, Velasco R, Guidon AC, Joubert B, Honnorat J. Neurological adverse events of immune checkpoint inhibitors and the development of paraneoplastic neurological syndromes. Lancet Neurol 2024; 23:81-94. [PMID: 38101905 DOI: 10.1016/s1474-4422(23)00369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 12/17/2023]
Abstract
Immune checkpoint inhibitors, a class of oncological treatments that enhance antitumour immunity, can trigger neurological adverse events closely resembling paraneoplastic neurological syndromes. Unlike other neurological adverse events caused by these drugs, post-immune checkpoint inhibitor paraneoplastic neurological syndromes predominantly affect the CNS and are associated with neural antibodies and cancer types commonly found also in spontaneous paraneoplastic neurological syndromes. Furthermore, post-immune checkpoint inhibitor paraneoplastic neurological syndromes have poorer neurological outcomes than other neurological adverse events of immune checkpoint inhibitors. Early diagnosis and initiation of immunosuppressive therapy are likely to be crucial in preventing the accumulation of neurological disability. Importantly, the neural antibodies found in patients with post-immune checkpoint inhibitor paraneoplastic neurological syndromes are sometimes detected before treatment, indicating that these antibodies might help to predict the development of neurological adverse events. Experimental and clinical evidence suggests that post-immune checkpoint inhibitor paraneoplastic neurological syndromes probably share immunological features with spontaneous paraneoplastic syndromes. Hence, the study of post-immune checkpoint inhibitor paraneoplastic neurological syndromes can help in deciphering the immunopathogenesis of paraneoplastic neurological syndromes and in identifying novel therapeutic targets.
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Affiliation(s)
- Antonio Farina
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - Macarena Villagrán-García
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy; Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sergio Muñiz-Castrillo
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Stanford Center for Sleep Sciences and Medicine, Palo Alto, CA, USA
| | - Roser Velasco
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d'Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain; Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Amanda C Guidon
- Harvard Medical School, Boston, MA, USA; Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bastien Joubert
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Department of Neurology, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jérôme Honnorat
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France.
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16
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Graus F. Clinical approach to diagnosis of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:79-96. [PMID: 38494298 DOI: 10.1016/b978-0-12-823912-4.00007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The correct diagnosis of a paraneoplastic neurologic syndrome (PNS) first requires the identification of the syndrome as one of those defined as high-risk (previously called classical) or intermediate-risk for cancer in the 2021 PNS diagnostic criteria. Testing for neuronal antibodies should be restricted to these syndromes as indiscriminate request decreases the diagnostic value of the antibodies. Identifying onconeural (high-risk for cancer) or intermediate-risk for cancer antibodies supports the paraneoplastic diagnosis and mandates the search for an underlying cancer. Tumor screening must follow the published guidelines. Repeated screening is indicated in neurologic syndromes with onconeural antibodies and patients with high-risk for cancer neurologic syndromes unless they present neuronal antibodies which are not associated with cancer. Neuronal antibodies should be screened by immunohistochemistry and confirmed by immunoblot (intracellular antigens) or cell-based assay (CBA) (surface antigens). Positive results only by immunoblot or CBA should be taken with caution. Although the 2021 diagnostic criteria for PNS do not capture all PNS, as they do not allow to diagnose definite PNS neurologic syndromes without neuronal antibodies, the updated criteria represent a step forward to differentiate true PNS from neurologic syndromes that coincide in time with cancer diagnosis without having a pathogenic link.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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17
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Dalmau J. Changing landscape in the field of paraneoplastic neurology: Personal perspectives over a 35-year career. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:11-32. [PMID: 38494272 DOI: 10.1016/b978-0-12-823912-4.00013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes are a group of rare disorders that have fascinated neurologists for more than a century. The discovery in the 1980s that many of these disorders occurred in association with antibodies against neuronal proteins revived the interest for these diseases. This chapter first traces the history of the paraneoplastic neurologic syndromes during the era that preceded the discovery of immune mechanisms and then reviews the immunologic period during which many of these syndromes were found to be associated with antibodies against intracellular onconeuronal proteins and pathogenic cytotoxic T-cell mechanisms. Alongside these developments, investigations on the antibody-mediated disorders of the peripheral nervous system, such as the myasthenic syndromes or neuromyotonia, provided suggestions for the study of the central nervous system (CNS) syndromes. These converging areas of research culminated with the groundbreaking discovery of a new category of CNS disorders mediated by antibodies against neuronal surface proteins or receptors. These disorders are not always paraneoplastic, and the understanding of these syndromes and mechanisms has changed the landscape of neurology and neurosciences.
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Affiliation(s)
- Josep Dalmau
- IDIBAPS-Hospital Clinic, University of Barcelona, Barcelona, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.
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18
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Liblau RS, Latorre D, Kornum BR, Dauvilliers Y, Mignot EJ. The immunopathogenesis of narcolepsy type 1. Nat Rev Immunol 2024; 24:33-48. [PMID: 37400646 DOI: 10.1038/s41577-023-00902-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/05/2023]
Abstract
Narcolepsy type 1 (NT1) is a chronic sleep disorder resulting from the loss of a small population of hypothalamic neurons that produce wake-promoting hypocretin (HCRT; also known as orexin) peptides. An immune-mediated pathology for NT1 has long been suspected given its exceptionally tight association with the MHC class II allele HLA-DQB1*06:02, as well as recent genetic evidence showing associations with polymorphisms of T cell receptor genes and other immune-relevant loci and the increased incidence of NT1 that has been observed after vaccination with the influenza vaccine Pandemrix. The search for both self-antigens and foreign antigens recognized by the pathogenic T cell response in NT1 is ongoing. Increased T cell reactivity against HCRT has been consistently reported in patients with NT1, but data demonstrating a primary role for T cells in neuronal destruction are currently lacking. Animal models are providing clues regarding the roles of autoreactive CD4+ and CD8+ T cells in the disease. Elucidation of the pathogenesis of NT1 will allow for the development of targeted immunotherapies at disease onset and could serve as a model for other immune-mediated neurological diseases.
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Affiliation(s)
- Roland S Liblau
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, Toulouse, France.
- Department of Immunology, Toulouse University Hospitals, Toulouse, France.
| | | | - Birgitte R Kornum
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Yves Dauvilliers
- National Reference Center for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France
- INSERM Institute for Neurosciences of Montpellier, Montpellier, France
| | - Emmanuel J Mignot
- Stanford University, Center for Narcolepsy, Department of Psychiatry and Behavioral Sciences, Palo Alto, CA, USA.
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Jean MJ, Samkoff L, Mohile N. Management of Paraneoplastic Syndromes in the Era of Immune Checkpoint Inhibitors. Curr Treat Options Oncol 2024; 25:42-65. [PMID: 38198120 DOI: 10.1007/s11864-023-01157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/11/2024]
Abstract
OPINION STATEMENT Our understanding of paraneoplastic neurologic syndromes (PNS) has blossomed over the past few decades. Clinicians have access to more robust diagnostic criteria and have a heightened index of suspicion for these disorders. Nonetheless, treatment, which typically includes immunosuppression, and response to treatment, varies. Due to persistent difficulty in making a definitive diagnosis, we favor empiric treatment when a possible diagnosis of PNS is suspected, and other alternative causes have substantially been excluded (e.g., infections, toxic-metabolic derangements, metastasis, or leptomeningeal disease). Treatment of the underlying cancer, if identified, is the first therapeutic step and can prevent disease worsening and in rare cases, can reverse neurologic symptoms. In addition to anti-cancer treatment, first line immunotherapies, which include corticosteroids, intravenous immunoglobulins (IVIG), or plasma exchange (PLEX) are typically used. If partial or no benefit is seen, second line immunotherapeutic agents such as rituximab are considered. Additionally, the severity of the initial presentation and possible risk for relapse influences the use of the latter agents. Symptomatic management is also an important component in our practice and will depend on the syndrome being treated. One of the more novel entities we are facing currently is the management of immune checkpoint (ICI)-induced PNS. In those cases, current American Society of Clinical Oncology (ASCO) guidelines are followed.
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Affiliation(s)
- Maxime Junior Jean
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Lawrence Samkoff
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Nimish Mohile
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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20
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Casagrande S, Zuliani L, Grisold W. Paraneoplastic encephalitis. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:131-149. [PMID: 38494274 DOI: 10.1016/b978-0-12-823912-4.00019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The first reports of encephalitis associated with cancer date to the 1960s and were characterized by clinical and pathologic involvement of limbic areas. This specific association was called limbic encephalitis (LE). The subsequent discovery of several "onconeural" antibodies (Abs), i.e., Abs targeting an antigen shared by neurons and tumor cells, supported the hypothesis of an autoimmune paraneoplastic etiology of LE and other forms of rapidly progressive encephalopathy. Over the past 20 years, similar clinical pictures with different clinical courses have been described in association with novel Abs-binding neuronal membrane proteins and proved to be pathogenic. The most well-known encephalitis in this group was described in 2007 as an association of a complex neuro-psychiatric syndrome, N-methyl-d-aspartate (NMDA) receptor-Abs, and ovarian teratoma in young women. Later on, nonparaneoplastic cases of NMDA receptor encephalitis were also described. Since then, the historical concept of LE and Ab associated encephalitis has changed. Some of these occur in fact more commonly in the absence of a malignancy (e.g., anti-LG1 Abs). Lastly, seronegative cases were also described. The term paraneoplastic encephalitis nowadays encompasses different syndromes that may be triggered by occult tumors.
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Affiliation(s)
- Silvia Casagrande
- Neurology Unit, Rovereto Hospital, Trento, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
| | - Luigi Zuliani
- Department of Neurology, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Wolfgang Grisold
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
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21
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Quinot V, Höftberger R. Pathogenesis and immunopathology of paraneoplastic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:33-54. [PMID: 38494287 DOI: 10.1016/b978-0-12-823912-4.00027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS) represent a rare group of immune-mediated complications associated with an underlying tumor. Ectopic protein expression in neoplastic cells or an aberrant immune regulation in the course of hematooncologic diseases or thymomas trigger an autoimmune response that may affect any part of the central and/or peripheral nervous system. Recent advances in drug therapies as well as novel animal models and neuropathologic studies have led to further insights on the immune pathomechanisms of PNS. Although the syndromes share common paths in pathogenesis, they may differ in the disease course, prognosis, and therapy targets, depending on the localization and type of antibody epitope. Neuropathologic hallmarks of PNS associated with antibodies directed against intracellular epitopes are characterized by T cell-dominated inflammation, reactive gliosis including microglial nodules, and neuronal degeneration. By contrast, the neuropathology of cell surface antibody-mediated PNS strongly depends on the targeted antigen and varies from B cell/plasma cell-dominated inflammation and well-preserved neurons together with a reduced expression of the target antigen in anti-NMDAR encephalitis to irreversible Purkinje cell loss in anti-P/Q-type VGCC antibody-associated paraneoplastic cerebellar degeneration. The understanding of different pathomechanisms in PNS is important because they strongly correspond with therapy response and prognosis, and should guide treatment decisions.
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Affiliation(s)
- Valérie Quinot
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria.
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22
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Masciocchi S, Businaro P, Scaranzin S, Morandi C, Franciotta D, Gastaldi M. General features, pathogenesis, and laboratory diagnostics of autoimmune encephalitis. Crit Rev Clin Lab Sci 2024; 61:45-69. [PMID: 37777038 DOI: 10.1080/10408363.2023.2247482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 10/02/2023]
Abstract
Autoimmune encephalitis (AE) is a group of inflammatory conditions that can associate with the presence of antibodies directed to neuronal intracellular, or cell surface antigens. These disorders are increasingly recognized as an important differential diagnosis of infectious encephalitis and of other common neuropsychiatric conditions. Autoantibody diagnostics plays a pivotal role for accurate diagnosis of AE, which is of utmost importance for the prompt recognition and early treatment. Several AE subgroups can be identified, either according to the prominent clinical phenotype, presence of a concomitant tumor, or type of neuronal autoantibody, and recent diagnostic criteria have provided important insights into AE classification. Antibodies to neuronal intracellular antigens typically associate with paraneoplastic neurological syndromes and poor prognosis, whereas antibodies to synaptic/neuronal cell surface antigens characterize many AE subtypes that associate with tumors less frequently, and that are often immunotherapy-responsive. In addition to the general features of AE, we review current knowledge on the pathogenic mechanisms underlying these disorders, focusing mainly on the potential role of neuronal antibodies in the most frequent conditions, and highlight current theories and controversies. Then, we dissect the crucial aspects of the laboratory diagnostics of neuronal antibodies, which represents an actual challenge for both pathologists and neurologists. Indeed, this diagnostics entails technical difficulties, along with particularly interesting novel features and pitfalls. The novelties especially apply to the wide range of assays used, including specific tissue-based and cell-based assays. These assays can be developed in-house, usually in specialized laboratories, or are commercially available. They are widely used in clinical immunology and in clinical chemistry laboratories, with relevant differences in analytic performance. Indeed, several data indicate that in-house assays could perform better than commercial kits, notwithstanding that the former are based on non-standardized protocols. Moreover, they need expertise and laboratory facilities usually unavailable in clinical chemistry laboratories. Together with the data of the literature, we critically evaluate the analytical performance of the in-house vs commercial kit-based approach. Finally, we propose an algorithm aimed at integrating the present strategies of the laboratory diagnostics in AE for the best clinical management of patients with these disorders.
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Affiliation(s)
- Stefano Masciocchi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Pietro Businaro
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Morandi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
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23
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Kerstens J, Titulaer MJ. Overview of treatment strategies in paraneoplastic neurological syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:97-112. [PMID: 38494299 DOI: 10.1016/b978-0-12-823912-4.00015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Treatment strategies in paraneoplastic neurological syndromes rely on the three pillars of tumor treatment, immunotherapy, and symptomatic treatment, the first one being by far the most important in the majority of patients and syndromes. Classically, antibodies against extracellular antigens are directly pathogenic, and patients with these syndromes are more responsive to immunomodulatory or immunosuppressive treatments than the ones with antibodies against intracellular targets. This chapter first discusses some general principles of tumor treatment and immunotherapy, followed by a closer look at specific treatment options for different clinical syndromes, focusing on symptomatic treatments.
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Affiliation(s)
- Jeroen Kerstens
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
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24
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Amylidi AL, Gogadis A, Yerolatsite M, Zarkavelis G, Torounidou N, Keramisanou V, Kampletsas E, Mauri D. Exploring a Rarity: Incidence of and Therapeutic Approaches for Neurological Complications and Hypophysitis in Cancer Patients on Immune Checkpoint Inhibitors-A Single-Center Study. Curr Oncol 2023; 30:10509-10518. [PMID: 38132400 PMCID: PMC10742161 DOI: 10.3390/curroncol30120766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Immune checkpoint inhibitors, such as anti-PD-1 and anti-CTLA-4 inhibitors, have become the standard of care for many cancer types. However, they induce immune-related adverse events (irAEs), including neurotoxicity and hypophysitis. The incidence and outcomes of neurotoxicity and hypophysitis in patients treated with immune checkpoint inhibitors are not well established. We conducted a retrospective study of 812 patients with solid cancers who received immune checkpoint inhibitors at the University General Hospital of Ioannina between January 2018 and January 2023. We assessed demographic and clinical data, including the severity of symptoms, treatment regimen, other irAEs, resolution type and time, and death. Two patients experienced neurotoxicity and two hypophysitis. All four patients required inpatient administration and received corticosteroids or/and hormone replacement. Three patients responded to the initial therapy, experiencing full recovery, while one patient was corticosteroid-resistant, and immunoglobin G was administered. Two patients never received immunotherapy after their toxicity due to the severity of symptoms; one patient continued monotherapy with nivolumab, changing from combination therapy with ipilimumab-nivolumab, while the fourth patient continued his initial treatment with nivolumab. Our study suggests that the incidence of neurotoxicity and hypophysitis in patients treated with immune checkpoint inhibitors is low, but careful monitoring and prompt treatment with corticosteroids are necessary for effective management.
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Affiliation(s)
- Anna Lea Amylidi
- Department of Medical Oncology, University Hospital of Ioannina, 45500 Ioannina, Greece; (A.G.); (M.Y.); (G.Z.); (N.T.); (V.K.); (E.K.); (D.M.)
- Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), 45445 Ioannina, Greece
| | - Aristeidis Gogadis
- Department of Medical Oncology, University Hospital of Ioannina, 45500 Ioannina, Greece; (A.G.); (M.Y.); (G.Z.); (N.T.); (V.K.); (E.K.); (D.M.)
- Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), 45445 Ioannina, Greece
| | - Melina Yerolatsite
- Department of Medical Oncology, University Hospital of Ioannina, 45500 Ioannina, Greece; (A.G.); (M.Y.); (G.Z.); (N.T.); (V.K.); (E.K.); (D.M.)
- Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), 45445 Ioannina, Greece
| | - George Zarkavelis
- Department of Medical Oncology, University Hospital of Ioannina, 45500 Ioannina, Greece; (A.G.); (M.Y.); (G.Z.); (N.T.); (V.K.); (E.K.); (D.M.)
- Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), 45445 Ioannina, Greece
| | - Nanteznta Torounidou
- Department of Medical Oncology, University Hospital of Ioannina, 45500 Ioannina, Greece; (A.G.); (M.Y.); (G.Z.); (N.T.); (V.K.); (E.K.); (D.M.)
- Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), 45445 Ioannina, Greece
| | - Varvara Keramisanou
- Department of Medical Oncology, University Hospital of Ioannina, 45500 Ioannina, Greece; (A.G.); (M.Y.); (G.Z.); (N.T.); (V.K.); (E.K.); (D.M.)
- Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), 45445 Ioannina, Greece
| | - Eleftherios Kampletsas
- Department of Medical Oncology, University Hospital of Ioannina, 45500 Ioannina, Greece; (A.G.); (M.Y.); (G.Z.); (N.T.); (V.K.); (E.K.); (D.M.)
- Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), 45445 Ioannina, Greece
| | - Davide Mauri
- Department of Medical Oncology, University Hospital of Ioannina, 45500 Ioannina, Greece; (A.G.); (M.Y.); (G.Z.); (N.T.); (V.K.); (E.K.); (D.M.)
- Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), 45445 Ioannina, Greece
- Faculty of Medicine, School of Health Sciences, University of Ioannina, 45500 Ioannina, Greece
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25
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Sato Y, Fujiwara S, Hata A, Kida Y, Masuda T, Amimoto H, Matsumoto H, Miyoshi K, Otsuka K, Tomii K. Clinical Impact of Pre-Existing Autoantibodies in Patients With SCLC Treated With Immune Checkpoint Inhibitor: A Multicenter Prospective Observational Study. JTO Clin Res Rep 2023; 4:100608. [PMID: 38162177 PMCID: PMC10755358 DOI: 10.1016/j.jtocrr.2023.100608] [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: 08/06/2023] [Revised: 10/15/2023] [Accepted: 11/15/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Although pretreatment autoantibodies have been associated with immune-related adverse events (irAEs) and immune checkpoint inhibitor treatment efficacy in some types of cancer, their importance has not been evaluated in patients with SCLC. Methods A multicenter prospective observational study was conducted on a total of 52 patients with extensive-disease SCLC who received immune checkpoint inhibitors in combination with chemotherapy as the first-line treatment at either of the six participating centers in Japan. Pretreatment serum samples were collected and analyzed for autoantibodies (rheumatoid factor, antinuclear antibodies, and antithyroid). Moreover, 12 antineuronal antibodies (AMPH, CV2, PNMA2, Ri, Yo, Hu, Recoverin, SOX1, Titin, Zic4, GAD65, and Tr) were analyzed using immunoblot assays. The primary end point was the incidence of irAEs with or without autoantibodies. The secondary end points were progression-free survival (PFS) and overall survival (OS) on the basis of the presence or absence of autoantibodies. Results PFS and OS were 4.4 and 25.3 months, respectively. Autoantibodies (rheumatoid factor, antinuclear antibodies, and antithyroid antibodies) were detected in 29 patients (56%). In total, irAEs were observed in 18 patients (35%); irAE incidence was 48% in the autoantibody-positive group and 17% in the autoantibody-negative group (p = 0.039). There was no difference in PFS or OS between patients with and without autoantibodies (4.4 mo versus 4.6 mo, p = 0.36; 15.3 mo versus 18.2 mo, p = 0.36). Antineuronal antibodies were detected in 16 patients (31%). However, the development of neurologic irAEs was not observed in both groups. Conclusions Vigilance is required against the development of irAEs in pretreatment antibody-positive patients.
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Affiliation(s)
- Yuki Sato
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Akito Hata
- Department of Thoracic Oncology, Kobe Minimally Invasive Cancer Center, Kobe, Japan
| | - Yoko Kida
- Department of Respiratory Medicine, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Takahiro Masuda
- Department of Respiratory Medicine, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Hisanori Amimoto
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Japan
| | - Hirotaka Matsumoto
- Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Kotoko Miyoshi
- Department of Respiratory Medicine, Shinko Hospital, Kobe, Japan
| | - Kojiro Otsuka
- Department of Respiratory Medicine, Shinko Hospital, Kobe, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
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Fonseca E, Cabrera-Maqueda JM, Ruiz-García R, Naranjo L, Diaz-Pedroche C, Velasco R, Macias-Gómez A, Milisenda JC, Muñoz-Farjas E, Pascual-Goñi E, Gállego Perez-Larraya J, Saiz A, Dalmau J, Blanco Y, Graus F, Martinez-Hernandez E. Neurological adverse events related to immune-checkpoint inhibitors in Spain: a retrospective cohort study. Lancet Neurol 2023; 22:1150-1159. [PMID: 37977714 DOI: 10.1016/s1474-4422(23)00335-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/07/2023] [Accepted: 08/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Neurological immune-related adverse events associated with immune checkpoint inhibitors can have several clinical manifestations, but the syndromes and prognostic factors are still not well known. We aimed to characterise and group the clinical features, with a special focus in patients presenting with encephalopathy, and to identify predictors of response to therapy and survival. METHODS This retrospective observational study included patients with neurological immune-related adverse events from 20 hospitals in Spain whose clinical information, serum samples, and CSF samples were studied at Hospital Clinic de Barcelona, Barcelona, Spain. Patients with pre-existing paraneoplastic syndromes or evidence of alternative causes for their neurological symptoms were excluded. We reviewed the clinical information, classified their clinical features, and determined the presence of neural antibodies. Neurological status was assessed by the treating physician one month after adverse event onset (as improvement vs no improvement) and at the last evaluation (complete recovery or modified Rankin Scale score decrease of at least 2 points, indicating good outcome, vs all other modified Rankin Scale scores, indicating poor outcome); if the participant had died, the date and cause of death were recorded. We used Fisher's exact tests and Mann-Whitney U tests to analyse clinical features, and multivariable logistic regression to analyse prognostic factors. FINDINGS From Jan 1, 2018, until Feb 1, 2023, 83 patients with suspected neurological immune-related adverse events after use of immune checkpoint inhibitors were identified, of whom 64 patients were included. These patients had a median age of 67 years (IQR 59-74); 42 (66%) were male and 22 (34%) were female. The predominant tumours were lung cancer (30 [47%] patients), melanoma (13 [21%] patients), and renal cell carcinoma (seven [11%] patients). Neural antibodies were detected in 14 (22%) patients; 52 (81%) patients had CNS involvement and 12 (19%) had peripheral nervous system involvement. Encephalopathy occurred in 45 (70%) patients, 12 (27%) of whom had antibodies or well defined syndromes consistent with definite paraneoplastic or autoimmune encephalitis, 24 (53%) of whom had encephalitis without antibodies or clinical features characteristic of a defined syndrome, and nine (20%) of whom had encephalopathy without antibodies or inflammatory changes in CSF or brain MRI. Nine (14%) of 64 patients had combined myasthenia and myositis, five of them with myocarditis. Even though 58 (91%) of 64 patients received steroids and 31 (48%) of 64 received additional therapies, 18 (28%) did not improve during the first month after adverse event onset, and 11 of these 18 people died. At the last follow-up for the 53 remaining patients (median 6 months, IQR 3-13), 20 (38%) had a poor outcome (16 deaths, one related to a neurological immune-related adverse event). Mortality risk was increased in patients with lung cancer (vs those with other cancers: HR 2·5, 95% CI 1·1-6·0) and in patients with encephalopathy without evidence of CNS inflammation or combined myocarditis, myasthenia, and myositis (vs those with the remaining syndromes: HR 5·0, 1·4-17·8 and HR 6·6, 1·4-31·0, respectively). INTERPRETATION Most neurological immune-related adverse events involved the CNS and were antibody negative. The presence of myocarditis, myasthenia, and myositis, of encephalopathy without inflammatory changes, or of lung cancer were independent predictors of death. Most deaths occurred during the first month of symptom onset. If our findings are replicated in additional cohorts, they could confirm that these patients need early and intensive treatment. FUNDING The Instituto de Salud Carlos III and the European Union.
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Affiliation(s)
- Elianet Fonseca
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jose M Cabrera-Maqueda
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Raquel Ruiz-García
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Immunology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Laura Naranjo
- Department of Immunology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Carmen Diaz-Pedroche
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Roser Velasco
- Department of Neurology, Hospital Universitari de Bellvitge-Institut Catalàd'Oncologia, l'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Jose C Milisenda
- Department of Internal Medicine, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Elena Muñoz-Farjas
- Department of Neurology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Elba Pascual-Goñi
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona Spain
| | | | - Albert Saiz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Yolanda Blanco
- Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Eugenia Martinez-Hernandez
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.
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Hong G, Zhao H, Yin Y, Shen H, Zeng Z, Yang J, Zhang L. Sintilimab-induced inflammatory myopathy in a patient with esophageal cancer: a case report. Front Immunol 2023; 14:1253463. [PMID: 37920461 PMCID: PMC10619899 DOI: 10.3389/fimmu.2023.1253463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023] Open
Abstract
The use of immune checkpoint inhibitors (ICIs) has shown remarkable efficacy in the treatment of various malignancies, significantly reshaping cancer treatment. However, as a result of the widespread use of ICIs, several immune-related adverse events (iRAEs) have emerged, some of which can be rare and potentially fatal. In this paper, we reported the earliest case of Sintilimab used in the treatment of esophageal cancer with severe inflammatory myopathy (involving the cardiac, respiratory, and skeletal muscles)in China. This patient was an elderly female who presented to our institution with progressive limb weakness and ptosis. Prior to the onset of symptoms, the patient had undergone a radical esophagectomy for esophageal cancer, experienced several cycles of of radiotherapy and chemotherapy, as well as two doses of Sintilimab treatment. Shortly after initiating immunotherapy, the patient developed symptoms including bilateral ptosis, limb weakness, and difficulty swallowing and breathing. The levels of creatine kinase and troponin I in the patient's blood were significantly elevated, and positive results were observed for anti-skeletal and anti-cardiac muscle antibodies, indicating that the patient might be developing ICIs-related inflammatory myopathy. Fortunately, the patient responded well to treatment including corticosteroids, plasmapheresis, intravenous immunoglobulin, and other supportive therapies. Here, we discuss the incidence, mechanisms, and management strategies of fatal iRAEs. Early detection and timely intervention may be critical in reducing the incidence and mortality rates of iRAEs and improving patient outcomes.
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Affiliation(s)
- Guo Hong
- Department of Neurology, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
- Shenzhen Clinical Research Centre for Geriatrics, Shenzhen People’s Hospital, Shenzhen, China
- Department of Neurology, Nantong Branch of Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Nantong, China
| | - Haina Zhao
- Department of Neurology, Institutes of Brain Science, Jiangsu Subei People's Hospital affiliated to Yangzhou University, Yangzhou, China
| | - Yuxuan Yin
- Department of Neurology, Yizheng People's Hospital, Yangzhou, China
| | - Hailin Shen
- Department of Neurology, Nantong Branch of Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Nantong, China
| | - Zhaohao Zeng
- Department of Neurology, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
- Shenzhen Clinical Research Centre for Geriatrics, Shenzhen People’s Hospital, Shenzhen, China
| | - Jianwei Yang
- Department of Ultrasound, Guangdong Second Provincial General Hospital, School of Medicine, Jinan University, Guangzhou, China
| | - Lili Zhang
- Department of Neurology, Jiangdu People's Hospital affiliated to Yangzhou University, Yangzhou, China
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28
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Smith KM, Britton JW, Thakolwiboon S, Chia NH, Gupta P, Flanagan EP, Zekeridou A, Lopez Chiriboga AS, Valencia Sanchez C, McKeon A, Pittock SJ, Dubey D. Seizure characteristics and outcomes in patients with neurological conditions related to high-risk paraneoplastic antibodies. Epilepsia 2023; 64:2385-2398. [PMID: 37366270 DOI: 10.1111/epi.17695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Seizures are a common manifestation of paraneoplastic neurologic syndromes. The objective of this study was to describe the seizure characteristics and outcomes in patients with high-risk paraneoplastic autoantibodies (>70% cancer association) and to determine factors associated with ongoing seizures. METHODS Patients from 2000 to 2020 with seizures and high-risk paraneoplastic autoantibodies were retrospectively identified. Factors associated with ongoing seizures at last follow-up were evaluated. RESULTS Sixty patients were identified (34 males, median age at presentation = 52 years). ANNA1-IgG (Hu; n = 24, 39%), Ma2-IgG (n = 14, 23%), and CRMP5-IgG (CV2; n = 11, 18%) were the most common underlying antibodies. Seizures were the initial presenting symptom in 26 (43%), and malignancy was present in 38 (63%). Seizures persisted for >1 month in 83%, and 60% had ongoing seizures, with almost all patients (55/60, 92%) still being on antiseizure medications at last follow-up a median of 25 months after seizure onset. Ongoing seizures at last follow-up were associated with Ma2-IgG or ANNA1-IgG compared to other antibodies (p = .04), highest seizure frequency being at least daily (p = .0002), seizures on electroencephalogram (EEG; p = .03), and imaging evidence of limbic encephalitis (LE; p = .03). Death occurred in 48% throughout the course of follow-up, with a higher mortality in patients with LE than in those without LE (p = .04). Of 31 surviving patients at last follow-up, 55% continued to have intermittent seizures. SIGNIFICANCE Seizures in the setting of high-risk paraneoplastic antibodies are frequently resistant to treatment. Ongoing seizures are associated with ANNA1-IgG and Ma2-IgG, high seizure frequency, and EEG and imaging abnormalities. Although a subset of patients may respond to immunotherapy and achieve seizure freedom, poor outcomes are frequently encountered. Death was more common among patients with LE.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Nicholas H Chia
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pranjal Gupta
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Vaišvilas M, Ciano-Petersen NL, Macarena Villagrán-García MD, Muñiz-Castrillo S, Vogrig A, Honnorat J. Paraneoplastic encephalitis: clinically based approach on diagnosis and management. Postgrad Med J 2023; 99:669-678. [PMID: 37389581 DOI: 10.1136/postgradmedj-2022-141766] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/25/2022] [Indexed: 11/04/2022]
Abstract
Paraneoplastic neurological syndromes (PNSs) comprise a subset of immune-mediated nervous system diseases triggered by an underlying malignancy. Each syndrome usually shows a distinct clinical presentation and outcome according to the associated neural antibodies. PNSs generally have a subacute onset with rapid progression and severe neurological disability. However, some patients may have hyperacute onset or even show chronic progression mimicking neurodegenerative diseases. Updated diagnostic criteria for PNS have been recently established in order to increase diagnostic specificity and to encourage standardisation of research initiatives related to PNS. Treatment for PNS includes oncological therapy and immunomodulation to halt neurological deterioration although current treatment options are seldom effective in reversing disability. Nevertheless, growing knowledge and better understanding of PNS pathogenesis promise better recognition, earlier diagnosis and novel treatment strategies. Considering that PNSs provide a model of effective anticancer immunity, the impact of these studies will extend far beyond the field of neurology.
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Affiliation(s)
- Mantas Vaišvilas
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Nicolás Lundahl Ciano-Petersen
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - M D Macarena Villagrán-García
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Sergio Muñiz-Castrillo
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Alberto Vogrig
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Jérôme Honnorat
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
- Department of Neuro-oncology, Hospices Civils de Lyon, Bron, France
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30
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Alsalem AN, Scarffe LA, Briemberg HR, Aaroe AE, Harrison RA. Neurologic Complications of Cancer Immunotherapy. Curr Oncol 2023; 30:5876-5897. [PMID: 37366923 DOI: 10.3390/curroncol30060440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Immunotherapy has revolutionized cancer treatment over the past decade. As it is increasingly introduced into routine clinical practice, immune-related complications have become more frequent. Accurate diagnosis and treatment are essential, with the goal of reduced patient morbidity. This review aims to discuss the various clinical manifestations, diagnosis, treatments, and prognosis of neurologic complications associated with the use of immune checkpoint inhibitors, adoptive T-cell therapies, and T-cell redirecting therapies. We also outline a suggested clinical approach related to the clinical use of these agents.
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Affiliation(s)
- Aseel N Alsalem
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Leslie A Scarffe
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Hannah R Briemberg
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Ashley E Aaroe
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Rebecca A Harrison
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
- Division of Medical Oncology, BC Cancer, University of British Columbia, Vancouver, BC V5Z 4E6, Canada
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31
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Graus F. Autoimmune Encephalitis and Related Syndromes. J Clin Med 2023; 12:jcm12113832. [PMID: 37298027 DOI: 10.3390/jcm12113832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
The field of autoimmune neurology has greatly expanded in the last decade [...].
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Casanova, 143, Floor 3rd, 08036 Barcelona, Spain
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32
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Farina A, Birzu C, Elsensohn MH, Picca A, Muñiz-Castrillo S, Vogrig A, Villagrán-García M, Ciano-Petersen NL, Massacesi L, Hervier B, Guégan S, Kramkimel N, Vano Y, Salem JE, Allenbach Y, Maisonobe T, Assaad S, Maureille A, Devic P, Weiss N, Pegat A, Maucort-Boulch D, Ricard D, Honnorat J, Psimaras D, Joubert B. Neurological outcomes in immune checkpoint inhibitor-related neurotoxicity. Brain Commun 2023; 5:fcad169. [PMID: 37389303 PMCID: PMC10306160 DOI: 10.1093/braincomms/fcad169] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 04/03/2023] [Accepted: 05/25/2023] [Indexed: 07/01/2023] Open
Abstract
While the spectrum of neurological immune checkpoint inhibitor-related adverse events is expanding, patients' outcomes are not well documented. This study aimed to assess outcomes of neurological immune-related adverse events and to identify prognostic factors. All patients experiencing grade ≥2 neurological immune-related adverse events identified at two clinical networks (French Reference Center for Paraneoplastic Neurological Syndromes, Lyon; and OncoNeuroTox, Paris) over five years were included. Modified Rankin scores were assessed at onset, 6, 12, 18 months, and last visit. A multi-state Markov model was used to estimate the transition rates between minor disability (mRS <3), severe disability (mRS 3-5), and death (mRS 6), over the study period. The state-to-state transition rates were estimated using maximum likelihood and variables were introduced into the different transitions to study their effects. A total of 147 patients were included out of 205 patients with a suspicion of neurological immune-related adverse events. The median age was 65 years (range 20-87) and 87/147 patients (59.2%) were male. Neurological immune-related adverse events involved the peripheral nervous system in 87/147 patients (59.2%), the central nervous system in 51/147 (34.7%), and both systems in 9/147 (6.1%). Paraneoplastic-like syndromes were observed in 30/147 patients (20.4%). Cancers included lung cancers (36.1%), melanoma (30.6%), urological cancers (15.6%), and others (17.8%). Patients were treated with programmed cell death protein (ligan) 1 (PD(L)1) inhibitors (70.1%), CTLA4 inhibitors (3.4%) or both (25.9%). Severe disability was reported in 108/144 patients (75.0%) at onset and in 33/146 patients (22.6%) at last visit (median follow-up duration: 12 months, range 0.5-50); 48/147 (32.7%) patients died, from cancer progression (17/48, 35.4%), neurological toxicity (15/48, 31.2%), other causes (10/48, 20.8%) or unknown causes (6/48, 12.5%). The rate of transition from severe to minor disability independently increased with melanoma [compared to lung cancer, hazard ratio = 3.26, 95%CI (1.27; 8.41)] and myositis/neuromuscular junction disorders [hazard ratio = 8.26, 95%CI (2.90; 23.58)], and decreased with older age [hazard ratio = 0.68, 95%CI (0.47; 0.99)] and paraneoplastic-like syndromes [hazard ratio = 0.29, 95%CI (0.09; 0.98)]. In patients with neurological immune-related adverse events, myositis/neuromuscular junction disorders and melanoma increase the transition rate from severe to minor disability, while older age and paraneoplastic-like syndromes result in poorer neurological outcomes; future studies are needed to optimize the management of such patients.
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Affiliation(s)
- Antonio Farina
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
- Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence 50139, Italy
| | - Cristina Birzu
- Department of Neurology 2 Mazarin, Sorbonne University, Brain Institute, INSERM UMR 1127, Groupe Hospitalier Pitié-Salpêtrière, Paris 75013, France
- OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments Groupe Hospitalier Pitié-Salpêtrière et Hôpital Percy, Paris 75561, France
| | | | | | - Sergio Muñiz-Castrillo
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
| | - Alberto Vogrig
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
| | - Macarena Villagrán-García
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
| | - Nicolás Lundahl Ciano-Petersen
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
| | - Luca Massacesi
- Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence 50139, Italy
| | - Baptiste Hervier
- Department of Internal Medicine, AP-HP, Hôpital St Louis, Paris 75010, France
| | - Sarah Guégan
- Department of Dermatology, AP-HP, Hôpital Cochin, Paris 75014, France
- Department of Dermatology, Université de Paris Cité, Paris 75006, France
| | - Nora Kramkimel
- Department of Dermatology, AP-HP, Hôpital Cochin, Paris 75014, France
| | - Yann Vano
- Department of Medical Oncology, AP-HP, Centre Hôpital Européen Georges-Pompidou, Paris 75015, France
| | - Joe Elie Salem
- Department of Pharmacology, Sorbonne University, INSERM, UNICO-GRECO Cardio-oncology Program, CIC-1901, AP-HP, Hôpital Pitié-Salpêtrière, F-75013 Paris, France
| | - Yves Allenbach
- APHP, Department of Internal Medicine, Sorbonne University, Sorbonne University, INSERM Groupe Hospitalier Pitié-Salpêtrière, Paris 75651, France
| | - Thierry Maisonobe
- APHP, Department of Clinical Neurophysiology, Sorbonne University, Paris 75013, France
| | - Souad Assaad
- Department of Medical Oncology, Léon Bérard Cancer Center, Lyon 69008, France
| | - Aurélien Maureille
- Department of Medical Oncology, Léon Bérard Cancer Center, Lyon 69008, France
| | - Perrine Devic
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, 69002 Lyon, France
- Department of Neurology, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon 69495, France
| | - Nicolas Weiss
- Department of Neurology, Sorbonne University, Hôpital de la Pitié-Salpêtrière, unité de Médecine Intensive Réanimation à orientation neurologique, Paris 75013, France
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Metabolic, Biliary and Fibro-Inflammatory Diseases of the Liver, Institute of Cardiometabolism and Nutrition (ICAN), Paris 75012, France
| | - Antoine Pegat
- Department of Neurological Functional Explorations, Hospices Civils de Lyon, Neurological Hospital, Bron 69500, France
| | - Delphine Maucort-Boulch
- Biostatistics—Bioinformatics Department, Public Health Unit. Hospices Civils de Lyon, Lyon 69003, France
- Laboratory of Biometry and Evolutionary Biology, University Claude Bernard Lyon 1, Villeurbanne 69622, France
- CNRS, UMR5558, Laboratory of Biometry and Evolutionary Biology, Biostatistics-Health Team, Villeurbanne 69622, France
| | - Damien Ricard
- OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments Groupe Hospitalier Pitié-Salpêtrière et Hôpital Percy, Paris 75561, France
- Neurology Department, Hôpital d’Instruction des Armées Percy, Service de Santé des Armées, Clamart 92140, France
| | - Jérôme Honnorat
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron 69677, France
- MeLiS - UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon 69008, France
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, 69002 Lyon, France
| | - Dimitri Psimaras
- Department of Neurology 2 Mazarin, Sorbonne University, Brain Institute, INSERM UMR 1127, Groupe Hospitalier Pitié-Salpêtrière, Paris 75013, France
- OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments Groupe Hospitalier Pitié-Salpêtrière et Hôpital Percy, Paris 75561, France
| | - Bastien Joubert
- Correspondence to: Bastien Joubert, MD, PhD French Reference Centre for Paraneoplastic Neurological Syndromes, Neurological Hospital 59 Boulevard Pinel, 69677 Bron Cedex, France E-mail:
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Marsili L, Marcucci S, LaPorta J, Chirra M, Espay AJ, Colosimo C. Paraneoplastic Neurological Syndromes of the Central Nervous System: Pathophysiology, Diagnosis, and Treatment. Biomedicines 2023; 11:biomedicines11051406. [PMID: 37239077 DOI: 10.3390/biomedicines11051406] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Paraneoplastic neurological syndromes (PNS) include any symptomatic and non-metastatic neurological manifestations associated with a neoplasm. PNS associated with antibodies against intracellular antigens, known as "high-risk" antibodies, show frequent association with underlying cancer. PNS associated with antibodies against neural surface antigens, known as "intermediate- or low-risk" antibodies, are less frequently associated with cancer. In this narrative review, we will focus on PNS of the central nervous system (CNS). Clinicians should have a high index of suspicion with acute/subacute encephalopathies to achieve a prompt diagnosis and treatment. PNS of the CNS exhibit a range of overlapping "high-risk" clinical syndromes, including but not limited to latent and overt rapidly progressive cerebellar syndrome, opsoclonus-myoclonus-ataxia syndrome, paraneoplastic (and limbic) encephalitis/encephalomyelitis, and stiff-person spectrum disorders. Some of these phenotypes may also arise from recent anti-cancer treatments, namely immune-checkpoint inhibitors and CAR T-cell therapies, as a consequence of boosting of the immune system against cancer cells. Here, we highlight the clinical features of PNS of the CNS, their associated tumors and antibodies, and the diagnostic and therapeutic strategies. The potential and the advance of this review consists on a broad description on how the field of PNS of the CNS is constantly expanding with newly discovered antibodies and syndromes. Standardized diagnostic criteria and disease biomarkers are fundamental to quickly recognize PNS to allow prompt treatment initiation, thus improving the long-term outcome of these conditions.
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Affiliation(s)
- Luca Marsili
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Samuel Marcucci
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Joseph LaPorta
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Martina Chirra
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, 05100 Terni, Italy
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Farina A, Villagrán-García M, Honnorat J. Neurological adverse events of immune checkpoint inhibitors: An update of clinical presentations, diagnosis, and management. Rev Neurol (Paris) 2023; 179:506-515. [PMID: 36934022 DOI: 10.1016/j.neurol.2023.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023]
Abstract
The use of immune checkpoint inhibitors (ICIs) has represented a major advance in cancer treatment. By enhancing endogenous immune responses to destroy cancer cells, ICIs can cause immune-related adverse events (irAEs), with possible involvement of any organ system. IrAEs are frequent, particularly those involving the skin or the endocrine system, and usually completely reversible after temporary immunosuppression, while neurological irAEs (n-irAEs) are relatively rare, often severe, and they carry a considerable risk of mortality and long-term disability. They usually affect the peripheral nervous system, mainly manifesting as myositis, polyradiculoneuropathy, or cranial neuropathy, and, less frequently, involve the central nervous system, causing encephalitis, meningitis, or myelitis. Although somehow reminiscent of the disorders that neurologists are familiar to deal with in their daily practice, n-irAEs are characterized by distinctive features from their idiopathic counterparts; for instance, myositis may have a predominant oculo-bulbar involvement reminiscent of myasthenia gravis and frequently associates with myocarditis; peripheral neuropathy, although often resembling Guillain-Barré syndrome, usually responds to corticosteroids. Remarkably, several associations between the neurological phenotype and the type of ICIs or the type of cancer have emerged in the last few years, and the growing administration of ICIs in patients with neuroendocrine cancers has led to an increased number of reports of paraneoplastic neurological syndromes (triggered or worsened by ICIs). This review aims to update current knowledge regarding the clinical presentation of n-irAEs. We also discuss the essential parts of the diagnostic approach, and we provide general recommendations for the management of these disorders.
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Affiliation(s)
- A Farina
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino, Università di Firenze, Firenze, Italy
| | - M Villagrán-García
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France
| | - J Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL, CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France.
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35
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Evaluation and management of acute high-grade immunotherapy-related neurotoxicity. Heliyon 2023; 9:e13725. [PMID: 36851967 PMCID: PMC9958505 DOI: 10.1016/j.heliyon.2023.e13725] [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: 06/30/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Immune checkpoint inhibitor monoclonal antibodies allow the host's immune system to attack tumors, which has revolutionized cancer care over the last decade. As the use of immune checkpoint inhibitors has expanded, so have autoimmune-like complications known as immune-related adverse events. These include the infrequent but increasingly more common, potentially deadly neurological immune related adverse events. When feeling acutely ill, patients will often seek care not from their oncologist but from their family physician, clinics, emergency, and urgent care sites, or other available providers. Thus, while assessing acutely ill cancer patients who are experiencing neurological symptoms, non-oncologists should be prepared to recognize, diagnose, and treat neurological immune related adverse events in addition to more familiar conditions. This narrative review is designed to update acute care clinicians on current knowledge and to present a symptom-based framework for evaluating and treating neurological immune related adverse events based on the leading immunotoxicity organizations' latest recommendations.
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Ramanathan S, Brilot F, Irani SR, Dale RC. Origins and immunopathogenesis of autoimmune central nervous system disorders. Nat Rev Neurol 2023; 19:172-190. [PMID: 36788293 DOI: 10.1038/s41582-023-00776-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/16/2023]
Abstract
The field of autoimmune neurology is rapidly evolving, and recent discoveries have advanced our understanding of disease aetiologies. In this article, we review the key pathogenic mechanisms underlying the development of CNS autoimmunity. First, we review non-modifiable risk factors, such as age, sex and ethnicity, as well as genetic factors such as monogenic variants, common variants in vulnerability genes and emerging HLA associations. Second, we highlight how interactions between environmental factors and epigenetics can modify disease onset and severity. Third, we review possible disease mechanisms underlying triggers that are associated with the loss of immune tolerance with consequent recognition of self-antigens; these triggers include infections, tumours and immune-checkpoint inhibitor therapies. Fourth, we outline how advances in our understanding of the anatomy of lymphatic drainage and neuroimmune interfaces are challenging long-held notions of CNS immune privilege, with direct relevance to CNS autoimmunity, and how disruption of B cell and T cell tolerance and the passage of immune cells between the peripheral and intrathecal compartments have key roles in initiating disease activity. Last, we consider novel therapeutic approaches based on our knowledge of the immunopathogenesis of autoimmune CNS disorders.
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Affiliation(s)
- Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
| | - Fabienne Brilot
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- School of Medical Science, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Russell C Dale
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.
- TY Nelson Department of Paediatric Neurology, Children's Hospital Westmead, Sydney, New South Wales, Australia.
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Möhn N, Mahjoub S, Duzzi L, Narten E, Grote-Levi L, Körner G, Seeliger T, Beutel G, Bollmann BA, Wirth T, Huss A, Tumani H, Grimmelmann I, Gutzmer R, Ivanyi P, Skripuletz T. Monocyte chemoattractant protein 1 as a potential biomarker for immune checkpoint inhibitor-associated neurotoxicity. Cancer Med 2023; 12:9373-9383. [PMID: 36794673 PMCID: PMC10166892 DOI: 10.1002/cam4.5695] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/25/2023] [Accepted: 02/02/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Oncological patients can benefit substantially from treatment with immune checkpoint inhibitors (ICI). However, there is a growing awareness of immune-related adverse events (irAE). Especially ICI-mediated neurological adverse events (nAE(+)), are tough to diagnose and biomarkers to identify patients at risk are missing. METHODS A prospective register with prespecified examinations was established for ICI treated patients in December 2019. At the time of data cut-off, 110 patients were enrolled and completed the clinical protocol. Herein, cytokines and serum neurofilament light chain (sNFL) from 21 patients were analyzed. RESULTS nAE of any grade were observed in 31% of the patients (n = 34/110). In nAE(+) patients a significant increase in sNFL concentrations over time was observed. Patients with higher-grade nAE had significantly elevated serum-concentrations of monocyte chemoattractant protein 1 (MCP-1) and brain-derived neurotrophic factor (BDNF) at baseline compared to individuals without any nAE (p < 0.01 and p < 0.05). CONCLUSION Here, we identified nAE to occur more frequently than previously reported. Increase of sNFL during nAE confirms the clinical diagnosis of neurotoxicity and might be a suitable marker for neuronal damage associated with ICI therapy. Furthermore, MCP-1 and BDNF are potentially the first clinical-class nAE predictors for patients under ICI therapy.
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Affiliation(s)
- Nora Möhn
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Susann Mahjoub
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Laura Duzzi
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Emily Narten
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Lea Grote-Levi
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Gudrun Körner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Tabea Seeliger
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Gernot Beutel
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Thomas Wirth
- Department of Gastroenterology, Hannover Medical School, Hannover, Germany
| | - André Huss
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | | | | | - Ralf Gutzmer
- Skin-Cancer-Center, Hannover Medical School, Hannover, Germany
- Department of Dermatology Venerology, Allergy and Phlebology, Hannover Medical School, Minden, Germany
| | - Philipp Ivanyi
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Müller-Jensen L, Knauss S, Ginesta Roque L, Schinke C, Maierhof SK, Bartels F, Finke C, Rentzsch K, Ulrich C, Mohr R, Stenzel W, Endres M, Boehmerle W, Huehnchen P. Autoantibody profiles in patients with immune checkpoint inhibitor-induced neurological immune related adverse events. Front Immunol 2023; 14:1108116. [PMID: 36845122 PMCID: PMC9945255 DOI: 10.3389/fimmu.2023.1108116] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Abstract
Background Neurological immune-related adverse events (irAE-n) are severe and potentially fatal toxicities of immune checkpoint inhibitors (ICI). To date, the clinical significance of neuronal autoantibodies in irAE-n is poorly understood. Here, we characterize neuronal autoantibody profiles in patients with irAE-n and compare these with ICI-treated cancer patients without irAE-n. Methods In this cohort study (DRKS00012668), we consecutively collected clinical data and serum samples of 29 cancer patients with irAE-n (n = 2 pre-ICI, n = 29 post-ICI) and 44 cancer control patients without irAE-n (n = 44 pre- and post-ICI). Using indirect immunofluorescence and immunoblot assays, serum samples were tested for a large panel of neuromuscular and brain-reactive autoantibodies. Results IrAE-n patients and controls received ICI treatment targeting programmed death protein (PD-)1 (61% and 62%), programmed death ligand (PD-L)1 (18% and 33%) or PD-1 and cytotoxic T-lymphocyte-associated protein (CTLA-)4 (21% and 5%). Most common malignancies were melanoma (both 55%) and lung cancer (11% and 14%). IrAE-n affected the peripheral nervous system (59%), the central nervous system (21%), or both (21%). Prevalence of neuromuscular autoantibodies was 63% in irAE-n patients, which was higher compared to ICI-treated cancer patients without irAE-n (7%, p <.0001). Brain-reactive autoantibodies targeting surface (anti-GABABR, -NMDAR, -myelin), intracellular (anti-GFAP, -Zic4, -septin complex), or unknown antigens were detected in 13 irAE-n patients (45%). In contrast, only 9 of 44 controls (20%) presented brain-reactive autoantibodies before ICI administration. However, seven controls developed de novo brain-reactive autoantibodies after ICI initiation, therefore, prevalence of brain-reactive autoantibodies was comparable between ICI-treated patients with and without irAE-n (p = .36). While there was no clear association between specific brain-reactive autoantibodies and clinical presentation, presence of at least one of six selected neuromuscular autoantibodies (anti-titin, anti-skeletal muscle, anti-heart muscle, anti-LRP4, anti-RyR, anti-AchR) had a sensitivity of 80% (95% CI 0.52-0.96) and a specificity of 88% (95% CI 0.76-0.95) for the diagnosis of myositis, myocarditis, or myasthenia gravis. Conclusion Neuromuscular autoantibodies may serve as a feasible marker to diagnose and potentially predict life-threatening ICI-induced neuromuscular disease. However, brain-reactive autoantibodies are common in both ICI-treated patients with and without irAE-n, hence, their pathogenic significance remains unclear.
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Affiliation(s)
- Leonie Müller-Jensen
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Samuel Knauss
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Lorena Ginesta Roque
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany
| | - Christian Schinke
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Smilla K. Maierhof
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Frederik Bartels
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Finke
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kristin Rentzsch
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Groß Grönau, Germany
| | - Claas Ulrich
- Hauttumorcentrum, Klinik für Dermatologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Raphael Mohr
- Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Werner Stenzel
- Institut für Neuropathologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Center for Stroke Research, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany,German Center for Neurodegenerative Diseases (DZNE), partner site, Berlin, Germany,German Center for Cardiovascular Research (DZHK), partner site, Berlin, Germany
| | - Wolfgang Boehmerle
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,*Correspondence: Wolfgang Boehmerle,
| | - Petra Huehnchen
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Berlin, Germany,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Seizures, Epilepsy, and NORSE Secondary to Autoimmune Encephalitis: A Practical Guide for Clinicians. Biomedicines 2022; 11:biomedicines11010044. [PMID: 36672553 PMCID: PMC9855825 DOI: 10.3390/biomedicines11010044] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022] Open
Abstract
The most recent International League Against Epilepsy (ILAE) classification has included "immune etiology" along with other well-known causes of epilepsy. This was possible thanks to the progress in detection of pathogenic neural antibodies (Abs) in a subset of patients, and resulted in an increased interest in identifying potentially treatable causes of otherwise refractory seizures. Most autoimmune encephalitides (AE) present with seizures, but only a minority of cases evolve to long-term epilepsy. The risk of epilepsy is higher for patients harboring Abs targeting intracellular antigens (T cell-mediated and mostly paraneoplastic, such as Hu, CV2/CRMP5, Ma2, GAD65 Abs), compared with patients with neuronal surface Abs (antibody-mediated and less frequently paraneoplastic, such as NMDAR, GABAbR, LGI1, CASPR2 Abs). To consider these aspects, conceptual definitions for two entities were provided: acute symptomatic seizures secondary to AE, and autoimmune-associated epilepsy, which reflect the different pathophysiology and prognoses. Through this manuscript, we provide an up-to-date review on the current state of knowledge concerning diagnosis and management of patients with Ab-mediated encephalitis and associated epilepsy. Special emphasis is placed on clinical aspects, such as brain magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) specificities, electroencephalographic (EEG) findings, cancer screening and suggestions for a rational therapeutic approach.
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Cuzzubbo S, Carpentier AF. Neurological adverse events of immune checkpoint blockade: from pathophysiology to treatment. Curr Opin Neurol 2022; 35:814-822. [PMID: 36226705 DOI: 10.1097/wco.0000000000001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW We review the recent advances in neurological toxicities of immune checkpoint inhibitors, with a focus on underlying pathophysiologic mechanisms and the implications on their therapeutical management. RECENT FINDINGS A growing number of cancer patients benefit from immune checkpoint agents and oncologists are increasingly confronted with these novel autoimmune syndromes. During the last years, further progresses have occurred in this field, notably in the identification of specific clinical patterns, such as the association of myasthenic syndrome with myositis and myocarditis, and polyradiculoneuropathies accompanied by cerebrospinal fluid lymphocytic pleocytosis. In addition, recent immune-histological studies improved the understanding of the pathophysiologic mechanisms behind immune-related neurotoxicities. SUMMARY Neurological toxicity is rare compared with other organs and systems, but its potential morbidity and mortality requires a prompt management. If there is a consensus for steroids as a first-line treatment, no exhaustive clinical data exist for other treatments. Recent advances in the knowledge of pathophysiological mechanisms (behind these toxicities) should be taken into account for the management of these patients. Drugs targeting T-cell mediated inflammation should be preferred in patients who are refractory to steroids, whereas therapies targeting humoral mechanisms should be considered in specific cases associated with autoantibodies such as immune-related myasthenic syndrome.
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Affiliation(s)
- Stefania Cuzzubbo
- Service de Neurologie, AP-HP, Hôpital Saint-Louis, Paris, France
- Université Paris Cité, Paris, France
| | - Antoine F Carpentier
- Service de Neurologie, AP-HP, Hôpital Saint-Louis, Paris, France
- Université Paris Cité, Paris, France
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41
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Müller-Jensen L, Zierold S, Versluis JM, Boehmerle W, Huehnchen P, Endres M, Mohr R, Compter A, Blank CU, Hagenacker T, Meier F, Reinhardt L, Gesierich A, Salzmann M, Hassel JC, Ugurel S, Zimmer L, Banks P, Spain L, Soon JA, Enokida T, Tahara M, Kähler KC, Seggewiss-Bernhardt R, Harvey C, Long GV, Schöberl F, von Baumgarten L, Hundsberger T, Schlaak M, French LE, Knauss S, Heinzerling LM. Characteristics of immune checkpoint inhibitor-induced encephalitis and comparison with HSV-1 and anti-LGI1 encephalitis: A retrospective multicentre cohort study. Eur J Cancer 2022; 175:224-235. [PMID: 36155116 DOI: 10.1016/j.ejca.2022.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/06/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Abstract
AIM Immune checkpoint inhibitor-induced encephalitis (ICI-iE) is a rare but life-threatening toxicity of immune checkpoint inhibitor treatment. We aim to identify the characteristics of ICI-iE and describe factors that discriminate it from herpes simplex virus (HSV)-1 encephalitis and anti-leucine-rich glioma-inactivated 1 (anti-LGI1) encephalitis, as two alternative entities of encephalitis. METHODS In this retrospective multicentre cohort study, we collected patients with ICI-iE reported to the Side Effect Registry Immuno-Oncology from January 2015 to September 2021 and compared their clinical features and outcome with 46 consecutive patients with HSV-1 or anti-LGI1 encephalitis who were treated at a German neurological referral centre. RESULTS Thirty cases of ICI-iE, 25 cases of HSV-1 encephalitis and 21 cases of anti-LGI1 encephalitis were included. Clinical presentation of ICI-iE was highly variable and resembled that of HSV-1 encephalitis, while impairment of consciousness (66% vs. 5%, p = .007), confusion (83% vs. 43%; p = .02), disorientation (83% vs. 29%; p = .007) and aphasia (43% vs. 0%; p = .007) were more common in ICI-iE than in anti-LGI1 encephalitis. Antineuronal antibodies (17/18, 94%) and MRI (18/30, 60%) were mostly negative in ICI-iE, but cerebrospinal fluid (CSF) showed pleocytosis and/or elevated protein levels in almost all patients (28/29, 97%). Three patients (10%) died of ICI-iE. Early immunosuppressive treatment was associated with better outcome (r = 0.43). CONCLUSIONS ICI-iE is a heterogeneous entity without specific clinical features. CSF analysis has the highest diagnostic value, as it reveals inflammatory changes in most patients and enables the exclusion of infection. Early treatment of ICI-iE is essential to prevent sequelae and death.
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Affiliation(s)
- Leonie Müller-Jensen
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany.
| | - Sarah Zierold
- SERIO Side Effect Registry Immuno-Oncology, Germany; Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany
| | - Judith M Versluis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Wolfgang Boehmerle
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany
| | - Petra Huehnchen
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Endres
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117 Berlin, Germany; Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Cluster of Excellence, 10117 Berlin, Germany; Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Stroke Research Berlin, 10117 Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Raphael Mohr
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Hepatology & Gastroenterology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Annette Compter
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Christian U Blank
- Department of Medical Oncology, Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Center Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Center Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Anja Gesierich
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Martin Salzmann
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Selma Ugurel
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Patricia Banks
- Andrew Love Cancer Centre, University Hospital Geelong, Geelong, Australia
| | - Lavinia Spain
- Medical Oncology Department, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Jennifer A Soon
- Medical Oncology Department, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Tomohiro Enokida
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan
| | - Makoto Tahara
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan
| | - Katharina C Kähler
- Department of Dermatology, Venerology and Allergology, University of Schleswig-Holstein Hospital, Campus Kiel, Germany
| | | | - Catriona Harvey
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Georgina V Long
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Florian Schöberl
- Department of Neurology, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany
| | - Louisa von Baumgarten
- Department of Neurology, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany; Division of Neuro-Oncology, Department of Neurosurgery, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany
| | - Thomas Hundsberger
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Max Schlaak
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Dermatology, Venerology and Allergology, Charitéplatz 1, 10117 Berlin, Germany
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany; Dr. Philip Frost, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Samuel Knauss
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; SERIO Side Effect Registry Immuno-Oncology, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Lucie M Heinzerling
- SERIO Side Effect Registry Immuno-Oncology, Germany; Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany; Department of Dermatology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
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Ralls F, Cutchen L, Grigg-Damberger MM. Recognizing New-Onset Sleep Disorders in Autoimmune Encephalitis Often Prompt Earlier Diagnosis. J Clin Neurophysiol 2022; 39:363-371. [PMID: 35239557 DOI: 10.1097/wnp.0000000000000820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Sleep/wake disorders are common in patients with autoimmune encephalitis, sometimes the most prominent or sole initial symptom, then delaying diagnosis. Sleep/wake disorders in autoimmune encephalitis vary and include severe sleeplessness, hypersomnia, central and/or obstructive sleep apnea, rapid eye movement sleep behavior disorder, indeterminate sleep/wake states, and loss of circadian sleep/wake rhythms. N-methyl- d aspartate receptor encephalitis (NMDAR) is often associated with insomnia, then hypersomnia and sleep-related central hypoventilation. Profound sleeplessness and rapid eye movement sleep behavior disorder are seen in patients with voltage-gated potassium channel-complex antibodies. Fragmented sleep and hypersomnia are common in paraneoplastic syndromes associated with anti-MA protein encephalitis; rapid eye movement sleep behavior disorder in those with antibodies against leucine-rich glioma inactivated protein (LGI1) or contactin-associated protein 2 (CASPR2) antibodies. Antibodies against a cell adhesion protein IGLON5 may result in obstructive sleep apnea, inspiratory stridor, disorganized nonrapid eye movement sleep, and excessive movements and parasomnias fragmenting nonrapid and rapid eye movement sleep. Recognizing a particular sleep/wake disorder is often a presenting or prominent feature in certain autoimmune encephalitis permit for earlier diagnosis. This is important because reduced morbidity and better short- and long-term outcomes are associated with earlier diagnosis and immunotherapies.
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Affiliation(s)
- Frank Ralls
- New Mexico Sleep Labs, Rio Rancho, New Mexico, U.S.A
| | - Lisa Cutchen
- Omni Sleep, Albuquerque, New Mexico, U.S.A.; and
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Immune Checkpoint Inhibitor Associated Autoimmune Encephalitis, Rare and Novel Topic of Neuroimmunology: A Case Report and Review of the Literature. Brain Sci 2022; 12:brainsci12060773. [PMID: 35741658 PMCID: PMC9221042 DOI: 10.3390/brainsci12060773] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/04/2022] [Accepted: 06/09/2022] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are being used in patients with various advanced malignancies, and patient outcomes have improved considerably. Although ICIs can effectively treat tumors, 30-60% of patients experience immune-related adverse events (irAEs). Autoimmune encephalitis (AE) is a rare irAE that has become a novel topic in neuroimmunology and has received increasing attention in recent years. Herein, we report a rare case of GAD65-antibody-associated AE after metastatic small cell lung cancer treatment with pembrolizumab. The patient received IVIg therapy for AE and continuous pembrolizumab therapy without suspension of tumor treatment. At 1 year follow-up, both the patient's AE symptoms and tumors were stable. We consider that the treatment of ICI-associated AE should be more individualized with prudent decision-making and should balance the tumor progression and AE treatment. In addition, we have also comprehensively reviewed the literature of ICI-associated AE, and summarized the clinical features, treatment, and prognosis of AE caused by ICI, thus broadening our understanding of the neurological complications caused by ICI.
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Ganaraja VH, Rezk M, Dubey D. Paraneoplastic neurological syndrome: growing spectrum and relevance. Neurol Sci 2022; 43:3583-3594. [DOI: 10.1007/s10072-022-06083-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/15/2022] [Indexed: 11/25/2022]
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Alberto T, Honnorat J, Joubert B. Sindromi neurologiche paraneoplastiche. Neurologia 2022. [DOI: 10.1016/s1634-7072(22)46429-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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46
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“Nivolumab-Induced Limbic Encephalitis Associated with Glutamic Acid Decarboxylase 65 Antibodies”. Can J Neurol Sci 2022:1-2. [DOI: 10.1017/cjn.2022.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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47
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Laderman L, Naveed O, LoPinto-Khoury C, Dotan E, Miron B. Paraneoplastic limbic encephalitis following treatment with single-agent pembrolizumab for advanced gastroesophageal adenocarcinoma. BMJ Case Rep 2022; 15:e247676. [PMID: 35609935 PMCID: PMC9131060 DOI: 10.1136/bcr-2021-247676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 01/22/2023] Open
Abstract
The use of immune checkpoint inhibitors is increasing in clinical practice. While they have provided significant benefit to many patients, a new category of adverse effects, immune-related adverse effects, has emerged with their use. These effects can range from mild to severe and affect nearly every organ system. A man in his 70swith metastatic gastro-oesophageal junction adenocarcinoma who received one cycle of third-line pembrolizumab presented after three episodes of transient left facial paresthesia, the last of which extended to the left extremities and disturbed peripheral vision of the left eye. He was found to have subclinical seizures and cerebrospinal fluid positive for Ma2/Ta paraneoplastic antibodies, consistent with paraneoplastic limbic encephalitis. We describe an unusual presentation of paraneoplastic limbic encephalitis. This case adds to the limited literature describing the association of paraneoplastic limbic encephalitis and treatment with immune checkpoint inhibitors as well as the observed associations with immune-related adverse events and treatment responses.
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Affiliation(s)
- Lauren Laderman
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Omer Naveed
- Department of Neurology, Temple University Health System Inc, Philadelphia, Pennsylvania, USA
| | - Carla LoPinto-Khoury
- Department of Neurology, Temple University Health System Inc, Philadelphia, Pennsylvania, USA
| | - Efrat Dotan
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Benjamin Miron
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
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48
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de Brito MH. Neurologic adverse events of cancer immunotherapy. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:270-280. [PMID: 35976306 PMCID: PMC9491428 DOI: 10.1590/0004-282x-anp-2022-s116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Cancer immunotherapy encompasses a wide range of treatment modalities that harness the anti-tumor effects of the immune system and have revolutionized oncological treatment in recent years, with approval for its use in more and more cancers. However, it is not without side effects. Several neurological adverse events have been recognized associated with immune checkpoint inhibitors (ICI) and chimeric antigen receptor (CAR) T-cell therapy, the two main classes of cancer immunotherapy. With the increase in the prevalence of oncological diseases and this type of therapy, it is improbable that neurologists, oncologists, hematologists, and other healthcare professionals who deal with cancer patients will not encounter this type of neurologic complication in their practice in the following years. This article aims to review the epidemiology, clinical manifestations, diagnosis, and management of neurological complications associated with ICI and CAR T-cell therapy.
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Affiliation(s)
- Marcelo Houat de Brito
- Universidade de São Paulo, Hospital das Clinicas, Departamento de Neurologia, São Paulo SP, Brazil
- Universidade de São Paulo, Instituto do Câncer do Estado de São Paulo, Departamento de Neurologia, Sao Paulo SP, Brazil
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49
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Gill AJ, Venkatesan A. Pathogenic mechanisms in neuronal surface autoantibody-mediated encephalitis. J Neuroimmunol 2022; 368:577867. [DOI: 10.1016/j.jneuroim.2022.577867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/22/2022] [Accepted: 04/09/2022] [Indexed: 11/16/2022]
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50
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Gastaldi M, Scaranzin S, Pietro B, Lechiara A, Pesce G, Franciotta D, Lorusso L. Paraneoplastic Neurological Syndromes: Transitioning Between the Old and the New. Curr Oncol Rep 2022; 24:1237-1249. [PMID: 35476177 DOI: 10.1007/s11912-022-01279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Paraneoplastic neurological syndromes (PNS) are caused by nervous system-targeting aberrant anti-tumoral immune responses. We review the updated criteria for PNS diagnosis, incorporating novel information on clinical phenotypes, neuronal autoantibodies (Nabs), and tumors. The impact of the oncologic use of immune checkpoint inhibitors (ICI) on PNS occurrence is also addressed. RECENT FINDINGS Clinical phenotypes and Nabs are redefined as "high/intermediate/low" risk, following the frequency of cancer association. Nabs, the diagnostic hallmark of PNS, can target intracellular or surface neuronal proteins, with important prognostic and pathogenic implications. Many novel assays have been incorporated into laboratory diagnostics, that is becoming increasingly complex. ICI fight tumors, but favor autoimmunity, thus increasing the incidence of PNS-like disorders. Overcoming the old PNS criteria, the new ones are centered around the presence of tumor. Clinical presentation, Nabs, and tumor findings are translated in diagnostic scores, providing a useful tool for PNS diagnosis and management.
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Affiliation(s)
- Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy.
| | - Silvia Scaranzin
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | | | - Anastasia Lechiara
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giampaola Pesce
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine (Dimi), University of Genova, Genova, Italy
| | - Diego Franciotta
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lorenzo Lorusso
- Neurology and Stroke Unit, Neuroscience Department, A.S.S.T.-Lecco, Merate (LC), Italy
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