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Yan SY, Fan JG. Application of immune checkpoint inhibitors and microsatellite instability in gastric cancer. World J Gastroenterol 2024; 30:2734-2739. [PMID: 38899328 PMCID: PMC11185298 DOI: 10.3748/wjg.v30.i21.2734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 06/03/2024] Open
Abstract
In this editorial we comment on the article by Li published in the recent issue of the World Journal of Gastroenterology. We focus specifically on the application of immune checkpoint inhibitors (ICIs) and microsatellite instability (MSI) in gastric cancer (GC). The four pillars of GC management have long been considered, including surgery, chemotherapy, radiotherapy and targeted therapy. However, immunotherapy has recently emerged as a "fifth pillar", and its use is rapidly expanding. There are four principal strategies for tumor immunotherapy: ICIs, tumor vaccines, adoptive immunotherapy and nonspecific immunomodulators. Of them, ICIs are the most advanced and widespread type of cancer immunotherapy for GC. Recent breakthrough results for ICIs have paved the way to a new era of cancer immunotherapy. In particular, inhibition of the PD-1/PD-L1 axis with ICIs, including nivolumab and pembrolizumab, has emerged as a novel treatment strategy for advanced GC. Unfortunately, these therapies are sometimes associated with often subtle, potentially fatal immune-related adverse events (irAEs), including dermatitis, diarrhea, colitis, endocrinopathy, hepatotoxicity, neuropathy and pneumonitis. We must be aware of these irAEs and improve the detection of these processes to prevent inappropriate discharges, emergency department revisits, and downstream complications. Recent studies have revealed that MSI-high or mismatch- repair-deficient tumors, regardless of their primary site, have a promising response to ICIs. So, it is important to detect MSI before applying ICIs for treatment of GC.
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Affiliation(s)
- Shi-Yan Yan
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Jian-Gao Fan
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
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2
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Saowapa S, Polpichai N, Siladech P, Wannaphut C, Tanariyakul M, Wattanachayakul P, Bernal DO, Garcia Pleitez H, Tijani L. Immunotherapy-induced colitis in metastatic colorectal cancer: a systematic review and meta-analysis. Proc AMIA Symp 2024; 37:613-622. [PMID: 38910824 PMCID: PMC11188800 DOI: 10.1080/08998280.2024.2342723] [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: 03/09/2024] [Accepted: 03/28/2024] [Indexed: 06/25/2024] Open
Abstract
Colorectal cancer (CRC) presents significant mortality risks, underscoring the urgency of timely diagnosis and intervention. Advanced stages of CRC are managed through chemotherapy, targeted therapy, immunotherapy, radiotherapy, and surgery. Immunotherapy, while effective in bolstering the immune system against cancer cells, often carries toxic side effects, including colitis. This study aimed to evaluate the incidence of colitis in patients with metastatic CRC (mCRC) undergoing various immunotherapy treatments. Through a systematic search of Google Scholar and PubMed databases from inception until November 2023, nine relevant studies were identified. Subgroup analyses revealed a higher incidence of colitis, particularly in patients treated with anti-cytotoxic T-lymphocyte-associated molecule-4 (anti-CTLA-4) and combination therapies compared to monotherapy with programmed cell death receptor-1 (PD-1) or programmed cell death ligand receptor-1 (PDL-1) inhibitors. Notably, naive-treated metastatic CRC patients exhibited elevated colitis incidences compared to those previously treated. In conclusion, anti-CTLA-4 and combination therapies, such as nivolumab plus ipilimumab, were associated with increased colitis occurrences in metastatic CRC patients, highlighting the need for vigilant monitoring and management strategies, especially in immunotherapy-naive individuals.
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Affiliation(s)
- Sakditad Saowapa
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Natchaya Polpichai
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, Illinois, USA
| | - Pharit Siladech
- Department of Internal Medicine, Mahidol University, Bangkok, Thailand
| | - Chalothorn Wannaphut
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Manasawee Tanariyakul
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | | | - Diego Olavarria Bernal
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Hector Garcia Pleitez
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Lukman Tijani
- Hematology and Oncology Department, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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3
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Tong X, Zhan T, Dong X, Xu D. Fever of unknown origin associated with immune checkpoint inhibitors. Front Immunol 2024; 15:1364128. [PMID: 38533499 PMCID: PMC10963505 DOI: 10.3389/fimmu.2024.1364128] [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: 01/01/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
Since the approval for the treatment of melanoma in 2014, immune checkpoint inhibitors (ICIs) have revolutionized the therapy pattern across various malignancies. Coinciding with their frequent usage, their adverse effects, including fever, cannot be neglected. In the context of cancer diseases and cancer treatments, fever of unknown origin (FUO), which has long posed a challenge for clinicians in terms of diagnosis and management, brings forth new connotation and significance. In this paper review, we present the concept of ICIs-associated FUO, consider activated immune system and elevated cytokines as common mechanisms by which ICIs induce fever and various immune-related adverse events (irAEs), summarize and compare the primary etiologies of ICI-associated FUO, and compare it with conventional types of FUO.
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Affiliation(s)
- Xu Tong
- The Second Clinical Medical College, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tao Zhan
- The Second Clinical Medical College, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaoqin Dong
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dong Xu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei, China
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4
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Rieger C, Pfister D, Heidenreich A. [Emergencies in cancer therapy: surgical indications under systemic therapy]. Aktuelle Urol 2024; 55:60-64. [PMID: 37607584 DOI: 10.1055/a-2129-7104] [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: 08/24/2023]
Abstract
Emergency surgery due to side-effects of cancer therapy in patients with metastatic disease of the genitourinary tract is rare. Nevertheless, there are a number of emergencies that require rapid intervention and should be recognized by every uro-oncologist. The following review will work out important side-effects requiring surgical treatment, highlighting the main symptoms and the initial management.
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Affiliation(s)
- Constantin Rieger
- Department of Urology, Urologic Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Koln, Germany
| | - David Pfister
- Department of Urology, Urologic Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Koln, Germany
| | - Axel Heidenreich
- Department of Urology, Urologic Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Koln, Germany
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5
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Pellegrino R, Fasano M, Morgillo F, Palladino G, Vassallo I, Pirozzi M, Imperio G, Auletta S, Ventura A, Panarese I, Federico A, Gravina AG. Vedolizumab as Rescue Therapy in Carboplatin-Gemcitabine-Induced Triggered Acute Severe Ulcerative Colitis Flare-Up. GASTROINTESTINAL DISORDERS 2023; 5:367-375. [DOI: 10.3390/gidisord5030030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
Approximately 20% of patients with ulcerative colitis (UC) develop acute severe UC (ASUC), for which intravenous systemic steroid therapy and possibly infliximab-based rescue therapy are generally imposed. However, there are no significant guideline recommendations on ASUC regarding vedolizumab as an alternative in this setting. A case report was presented where a patient with steroid-dependent UC developed ASUC induced by second-line chemotherapy. Treatment with intravenous methylprednisolone was imposed, but there was no reduction in bowel movements in the days following admission. Rescue therapy with infliximab was contraindicated because of the oncologic history. Surgical consultation, contraindicated colectomy, and administration of vedolizumab 300 mg were initiated. After infusion with vedolizumab, there was a significant reduction in bowel movements starting the day after infusion until normalisation of bowel movements within three days and the concomitant normalisation of inflammatory indices. The patient is currently in clinical remission, on therapy with vedolizumab 108 mg subcutaneously every two weeks, and is in oncologic follow-up for pulmonary neoplasm. This case highlights the novel potential of vedolizumab as a possible rescue therapy in ASUC, especially in special populations, where it may offer a better safety profile. Although cyclosporine and infliximab still represent the mainstays of salvage therapy for steroid-refractory ASUC, new therapeutic agents may also be effective, such as vedolizumab, ustekinumab, and anti-Janus kinase agents.
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Affiliation(s)
- Raffaele Pellegrino
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Morena Fasano
- Medical Oncology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Floriana Morgillo
- Medical Oncology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Giovanna Palladino
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Isabella Vassallo
- Medical Oncology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Mario Pirozzi
- Medical Oncology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Giuseppe Imperio
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Salvatore Auletta
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Andrea Ventura
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Iacopo Panarese
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Alessandro Federico
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Antonietta Gerarda Gravina
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
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Kazemzadeh K, Behrouzieh S, Rezaei N. Shedding light on the side effects of immunotherapies used for leukemia: an updated review of the literature. Expert Rev Anticancer Ther 2023; 23:1193-1204. [PMID: 37812581 DOI: 10.1080/14737140.2023.2267760] [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: 06/26/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Leukemia is an abnormal clonal development of leukemic cells originating from the bone marrow, which is widely known for its significant prevalence and mortality rate. Chemotherapy, surgery, radiation, and combination therapies have been its routine therapeutic methods; however, the advent of cancer immunotherapy is known as revolutionary for its higher efficacy and lesser toxicity. AREAS COVERED Immunotherapy boosts the body's immune system by using components from other living organisms. Although immunotherapy seems to be safer than chemotherapy, many studies have noticed different immune-related side effects in various body systems (e.g. cardiovascular, neurologic) which we have reviewed in this investigation as the main goal. We tried to describe immunotherapy-related side effects in human body systems in detail. EXPERT OPINION Being aware of these side effects leads to better clinical decision-making for each individual, and a one-step-ahead management in case of occurrence. We also briefly discussed the role of immunotherapy in treating leukemia as one of the most prevalent cancers in children and tried to emphasize that it is crucial to monitor adverse events as they may remain obscure until adolescence.
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Affiliation(s)
- Kimia Kazemzadeh
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Network of Neurosurgery and Artificial Intelligence (NONAI), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Sadra Behrouzieh
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Neurosurgery and Artificial Intelligence (NONAI), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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7
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Shirwaikar Thomas A, Hanauer S, Wang Y. Immune Checkpoint Inhibitor Enterocolitis vs Idiopathic Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2023; 21:878-890. [PMID: 36270617 DOI: 10.1016/j.cgh.2022.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 02/07/2023]
Abstract
Immune checkpoint inhibitors have revolutionized management of advanced malignancies. However, their use is frequently complicated by immune related adverse events (irAEs), immune checkpoint inhibitor enterocolitis (IMEC) being the most common toxicity. IMEC is a distinct form of bowel inflammation that is highly reminiscent of idiopathic inflammatory bowel disorders (Crohn's disease, ulcerative colitis, and microscopic colitis). In this review, we highlight the similarities and differences in the pathophysiology, clinical presentation, evaluation, and management of these overlapping immune inflammatory bowel disorders. IMEC is an inflammatory bowel disease-like irAE that occurs as an outcome of disruption of intestinal immune surveillance and gut dysbiosis. Clinical and endoscopic presentation of both entities is strikingly similar, which often guides management. Though well established in inflammatory bowel disease, little is known about the long term outcomes of IMEC.
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Affiliation(s)
- Anusha Shirwaikar Thomas
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Hanauer
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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8
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Zhou G, Zhang N, Meng K, Pan F. Interaction between gut microbiota and immune checkpoint inhibitor-related colitis. Front Immunol 2022; 13:1001623. [PMID: 36389768 PMCID: PMC9648670 DOI: 10.3389/fimmu.2022.1001623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/10/2022] [Indexed: 09/23/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have become a promising therapeutic strategy for malignant tumors, improving patient prognosis, along with a spectrum of immune-related adverse events (irAEs), including gastrointestinal toxicity, ICI-related colitis (IRC), and diarrhea. The gut microbiota has been suggested as an important regulator in the pathogenesis of IRC, and microbiota modulations like probiotics and fecal microbiota transplantation have been explored to treat the disease. This review discusses the interaction between the gut microbiota and IRC, focusing on the potential pathogenic mechanisms and promising interventions.
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Affiliation(s)
- Guanzhou Zhou
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- School of Medicine, Nankai University, Tianjin, China
| | - Nana Zhang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Ke Meng
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Fei Pan
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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9
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Fane LS, Efird JT, Jindal C, Biswas T. Dermatological Autoimmune Considerations of Immune Checkpoint Therapy. Biomedicines 2022; 10:biomedicines10102339. [PMID: 36289601 PMCID: PMC9598603 DOI: 10.3390/biomedicines10102339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/12/2022] [Accepted: 09/17/2022] [Indexed: 11/17/2022] Open
Abstract
The most common immune-related adverse events (irAEs) involve the skin, and several serve as predictors of response to immune checkpoint inhibitor (ICI) therapy, especially in melanoma. Patients with pre-existing skin autoimmune diseases (ADs) have been excluded from ICI studies for safety concerns, yet recent research has shown that dermatological ADs can be managed without discontinuing ICI therapy. Patients with ADs respond as well or better to ICIs and can be included as candidates in clinical trials. Frequently taken during ICI therapy, steroids impair immunotherapy efficacy in certain anatomical sites of tumors but not others, including the brain. ICI efficacy can be enhanced by radiotherapy without increasing adverse events, as neoadjuvant radiotherapy is thought to sensitize tumors to ICIs. This perspective highlights clinical autoimmune considerations of ICI therapy in melanoma and discusses important areas for future exploration.
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Affiliation(s)
- Lauren S. Fane
- MD University Program, Case Western Reserve University School of Medicine, Cleveland, OH 44016, USA
| | - Jimmy T. Efird
- VA Cooperative Studies Program Coordinating Center, Boston, MA 02130, USA
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, OH 44015, USA
- Correspondence:
| | - Charulata Jindal
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Tithi Biswas
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, OH 44015, USA
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44015, USA
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Ibarra Rovira J, Thirumurthi S, Taggart M, Yilmaz B, Lin H, Zhong LL, Ejezie CL, Akhmedzhanov FO, Zarifa A, Leung CH, Hong DS, Vikram R. Role of Abdominal and Pelvic CT Scans in Diagnosis of Patients with Immunotherapy-Induced Colitis. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2022; 5:32-36. [PMID: 35664090 PMCID: PMC9153249 DOI: 10.36401/jipo-21-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/09/2022] [Accepted: 02/19/2022] [Indexed: 11/18/2022]
Abstract
Introduction: Colitis is one of the most common immune-related adverse events in patients receiving immune checkpoint inhibitors. Although radiographic changes on computed tomography (CT), such as mild diffuse bowel thickening, mesenteric fat stranding, and mucosal enhancement, have been reported, the utility of CT in diagnosis of patients with suspected immune-related colitis is not well documented. The aim of this retrospective study was to determine the value of CT scans in diagnosis of immunotherapy-induced colitis. Methods: CT scans of the abdomen and pelvis of 34 patients receiving immunotherapy who had a clinical diagnosis of immunotherapy-induced colitis and 19 patients receiving immunotherapy without clinical symptoms of colitis (controls) were evaluated. Segments of the colon (rectum, sigmoid, descending, transverse, ascending, and cecum) were assessed independently by two abdominal imaging specialists, blinded to the clinical diagnosis. Each segment was assessed for radiographic signs such as mucosal enhancement, wall thickening, distension, and periserosal fat stranding. The presence of any of the signs was considered radiographic evidence of colitis. Results: CT findings suggestive of colitis was seen in 20 of 34 patients with symptoms of colitis and in 5 of 19 patients without symptoms of colitis. The sensitivity, specificity, positive predictive value, and negative predictive value for colitis on CT were 58.8%, 73.7%, 80%, and 50%, respectively. Conclusions: We found that CT had a low sensitivity, specificity, and negative predictive value for the diagnosis of immunotherapy-induced colitis. We therefore conclude that CT has a limited role in the diagnosis of patients with suspected uncomplicated immune-related colitis.
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Affiliation(s)
- Juan Ibarra Rovira
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melissa Taggart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bulent Yilmaz
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Linda Lee Zhong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chinenye Lynette Ejezie
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fechukwu O. Akhmedzhanov
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abdulrazzak Zarifa
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cheuk Hong Leung
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David S. Hong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raghunandan Vikram
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Tang L, Wang J, Lin N, Zhou Y, He W, Liu J, Ma X. Immune Checkpoint Inhibitor-Associated Colitis: From Mechanism to Management. Front Immunol 2021; 12:800879. [PMID: 34992611 PMCID: PMC8724248 DOI: 10.3389/fimmu.2021.800879] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 11/29/2021] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs), as one of the innovative types of immunotherapies, including programmed cell death-1 (PD-1), programmed cell death-ligand 1 (PD-L1), and cytotoxic T lymphocyte antigen 4 (CTLA-4) inhibitors, have obtained unprecedented benefit in multiple malignancies. However, the immune response activation in the body organs could arise immune-related adverse events (irAEs). Checkpoint inhibitor colitis (CIC) is the most widely reported irAEs. However, some obscure problems, such as the mechanism concerning gut microbiota, the confusing differential diagnosis with inflammatory bowel disease (IBD), the optimal steroid schedule, the reintroduction of ICIs, and the controversial prognosis features, influence the deep understanding and precise diagnosis and management of CIC. Herein, we based on these problems and comprehensively summarized the relevant studies of CIC in patients with NSCLC, further discussing the future research direction of this specific pattern of irAEs.
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Affiliation(s)
- Liansha Tang
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jialing Wang
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Nan Lin
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yuwen Zhou
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenbo He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiyan Liu
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xuelei Ma
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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12
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Kichloo A, Albosta M, Dahiya D, Guidi JC, Aljadah M, Singh J, Shaka H, Wani F, Kumar A, Lekkala M. Systemic adverse effects and toxicities associated with immunotherapy: A review. World J Clin Oncol 2021; 12:150-163. [PMID: 33767971 PMCID: PMC7968107 DOI: 10.5306/wjco.v12.i3.150] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/21/2021] [Accepted: 02/20/2021] [Indexed: 02/06/2023] Open
Abstract
Immunotherapy is rapidly evolving secondary to the advent of newer immunotherapeutic agents and increasing approval of the current agents by the United States Food and Drug Administration to treat a wide spectrum of cancers. Immunotherapeutic agents have gained immense popularity due to their tumor-specific action. Immunotherapy is slowly transforming into a separate therapeutic entity, and the fifth pillar of management for cancers alongside surgery, radiotherapy, chemotherapy, and targeted therapy. However, like any therapeutic entity it has its own adverse effects. With the increasing use of immuno-therapeutic agents, it is vital for physicians to acquaint themselves with these adverse effects. The aim of this review is to investigate the common systemic adverse effects and toxicities associated with the use of different classes of immunotherapeutic agents. We provide an overview of potential adverse effects and toxicities associated with different classes of immunotherapeutic agents organized by organ systems, as well as an extensive discussion of the current recommendations for treatment and clinical trial data. As we continue to see increasing usage of these agents in clinical practice, it is vital for physicians to familiarize themselves with these effects.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Michael Albosta
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Dushyant Dahiya
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Jean Claude Guidi
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Michael Aljadah
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 53201, United States
| | - Jagmeet Singh
- Department of Nephrology, Guthrie Robert Packer Hospital, Sayre, PA 18840, United States
| | - Hafeez Shaka
- Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, IL 60612, United States
| | - Farah Wani
- Department of Family Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Akshay Kumar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Manidhar Lekkala
- Department of Hematology and Oncology, University of Rochester Medical Center, Rochester, NY 14642, United States
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13
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Dahiya DS, Wani F, Guidi JC, Kichloo A. Gastrointestinal Adverse Effects of Immunotherapeutic Agents: A Systematic Review. Gastroenterology Res 2020; 13:227-232. [PMID: 33447301 PMCID: PMC7781271 DOI: 10.14740/gr1340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/05/2020] [Indexed: 12/26/2022] Open
Abstract
The utilization of immunotherapy is increasing to the point of becoming the fifth pillar of management alongside surgical intervention, chemotherapy, radiotherapy and targeted therapy. However, gastrointestinal adverse effects and toxicities have been frequently cited with its use. As per literature, the most common adverse effect of immune checkpoint inhibitors is watery and non-bloody diarrhea. Adoptive cell therapy can lead to delayed, on-target but off-tumor adverse effects which are unknown and may be life-threatening. The use of anti-angiogenic monoclonal antibodies can lead to bowel perforations, whereas epidermal growth factor receptor inhibitors and anti-HER2 agents are frequently associated with diarrhea. Minimal adverse effects have been associated with therapeutic cancer vaccines; however, additional studies are needed to determine their efficacy and potential toxicities. To provide an in-depth review of the gastrointestinal side effects of immunotherapeutic agents, we performed a thorough literature search using multiple online search engines such as PubMed, Google Scholar and Ovid MEDLINE, along with a review of the guidelines from the United States Food and Drug Administration (FDA) and the Cancer Research Institute on immunotherapy. In this systematic review, we detail the gastrointestinal adverse effects of immunotherapy and describe their management. With the advent of newer immunotherapeutic agents and the consistent approval of current agents by FDA for a wide spectrum of cancers, it is vital for physicians to familiarize themselves with their adverse effects for prompt diagnosis and early intervention to decrease adverse outcomes.
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Affiliation(s)
| | - Farah Wani
- Department of Family Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Jean Claude Guidi
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Saginaw, MI, USA.,Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
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Singh BP, Marshall JL, He AR. Workup and Management of Immune-Mediated Colitis in Patients Treated with Immune Checkpoint Inhibitors. Oncologist 2020; 25:197-202. [PMID: 32162824 PMCID: PMC7066712 DOI: 10.1634/theoncologist.2018-0304] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/19/2019] [Indexed: 12/14/2022] Open
Abstract
As the use of immune checkpoint inhibitors for several different malignancies becomes more mainstream, their side-effect profile raises new challenges. In 2011, the Food and Drug Administration approved the first checkpoint inhibitor for the treatment of advanced melanoma, and since then, checkpoint inhibitors have demonstrated efficacy in many other tumor types. Given the frequent use of immune checkpoint inhibitors in a wide range of cancers today, the diagnosis and management of their immune-mediated toxicities need special attention. One of the most common is immune-mediated colitis. Workup and management of immune-mediated colitis can be challenging and is the purpose of this review. KEY POINTS: Rate of immune mediated colitis differ from different kind of immune checkpoint inhibitor treatment. To work up immune-mediated colitis, tests to rule out infectious etiologies of diarrhea, colonoscopy and abdominal image will help to differentiate immune mediated colitis from colitis from other etiology. Patients with mild colitis can be managed with supportive therapies alone, but more severe cases may require immunomodulators such as steroid. Refractory cases may require tumor necrosis factor (TNF) inhibitors, such as infliximab in addition to steroid treatment.
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Affiliation(s)
- Bhavana Pendurthi Singh
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical CenterWashingtonDCUSA
| | - John L. Marshall
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical CenterWashingtonDCUSA
| | - Aiwu Ruth He
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical CenterWashingtonDCUSA
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Marin-Acevedo JA, Chirila RM, Dronca RS. Immune Checkpoint Inhibitor Toxicities. Mayo Clin Proc 2019; 94:1321-1329. [PMID: 31272574 DOI: 10.1016/j.mayocp.2019.03.012] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/01/2019] [Accepted: 03/13/2019] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibitors are molecules that increase the endogenous immune response against tumors. They have revolutionized the field of oncology. Since their initial approval for the treatment of advanced melanoma, their use has expanded to the treatment of several other advanced cancers. Unfortunately, immune checkpoint inhibitors have also been associated with the emergence of a new subset of autoimmune-like toxicities, known as immune-related adverse events. These toxicities differ depending on the agent, malignancy, and individual susceptibilities. Although the skin and colon are most commonly involved, any organ may be affected, including the liver, lungs, kidneys, and heart. Most of these toxicities are diagnosed by excluding other secondary infectious or inflammatory causes. Corticosteroids are commonly used for treatment of moderate and severe immune-related adverse events, although additional immunosuppressive therapy may occasionally be required. The occurrence of immune-related toxicities may require discontinuation of immunotherapy, depending on the specific toxicity and its severity. In this article, we provide a focused review to familiarize practicing clinicians with this important topic given that the use of immune checkpoint inhibitors continues to increase.
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Affiliation(s)
| | - Razvan M Chirila
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Roxana S Dronca
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL.
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Wang T, Zheng N, Luo Q, Jiang L, He B, Yuan X, Shen L. Probiotics Lactobacillus reuteri Abrogates Immune Checkpoint Blockade-Associated Colitis by Inhibiting Group 3 Innate Lymphoid Cells. Front Immunol 2019; 10:1235. [PMID: 31214189 PMCID: PMC6558076 DOI: 10.3389/fimmu.2019.01235] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/15/2019] [Indexed: 12/13/2022] Open
Abstract
Immune checkpoint blockade (ICB) immunotherapy increases antitumor immunity by blocking cytotoxic-T-lymphocyte-associated protein 4 (CTLA-4) or programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) and displays robust clinical responses in various cancers. However, ICB immunotherapy also triggers severe inflammatory side effects, known as immune-related adverse effects (irAEs). One of the most common toxicities is immune checkpoint blockade-associated colitis (ICB associated colitis). The exact mechanism of ICB associated colitis remains to be explored. Here, we combined ICB (anti-CTLA-4 and anti-PD-1) treatment with a standard colitis model, in which a more severe form of colitis is induced in mice, to recapitulate the clinical observations in patients receiving combined ipilimumab (anti-CTLA-4) and nivolumab (anti-PD-1) therapy, during which colitis is the most frequent complication encountered. We found that the composition of the gut microbiota changed in ICB associated colitis. Principal component analysis of the gut microbiome showed an obvious reduction in the abundance of Lactobacillus in severe ICB associated colitis. Lactobacillus depletion completely by vancomycin augmented the immunopathology of ICB. Furthermore, we found that the ICB toxicity could be totally eliminated via the administration of a widely available probiotic Lactobacillus reuteri (L.reuteri). Oral administration of L. reuteri therapeutically inhibited the development and progression of colitis, thus ameliorating the loss of body weight and inflammatory status induced by ICB treatment. Mechanistically, the protective effect of L. reuteri was associated with a decrease in the distribution of group 3 innate lymphocytes (ILC3s) induced by ICB associated colitis. In conclusion, our study highlights the immunomodulatory mechanism of the gut microbiota and suggests that manipulating the gut microbiota by administrating L. reuteri can mitigate the autoimmunity induced by ICB, thus allowing ICB immunotherapy to stimulate the desired immune response without an apparent immunopathology.
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Affiliation(s)
- Tingting Wang
- Department of Clinical Laboratory, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Naisheng Zheng
- Department of Clinical Laboratory, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qin Luo
- Department of Clinical Laboratory, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Jiang
- Department of Gynecology and Obstetrics, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Baokun He
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiangliang Yuan
- Department of Clinical Laboratory, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lisong Shen
- Department of Clinical Laboratory, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Rocha M, Correia de Sousa J, Salgado M, Araújo A, Pedroto I. Management of Gastrointestinal Toxicity from Immune Checkpoint Inhibitor. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 26:268-274. [PMID: 31328141 DOI: 10.1159/000494569] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/09/2018] [Indexed: 12/14/2022]
Abstract
Immune checkpoint inhibitors have shown anti-tumour activity in cancers such as melanoma, renal cell carcinoma, non-small-cell lung cancer, urothelial carcinoma, colorectal cancer, and Hodgkin's lymphoma. Though immune checkpoint inhibitors have revolutionized the treatment and prognosis of some advanced malignancies, they are also associated with a significant risk of immune-related adverse events. These adverse events can occur in any organ system, but gastrointestinal side effects are among the most commonly reported, with manifestations ranging from mild diarrhoea to severe colitis, sharing some features with inflammatory bowel disease. Anticipating a greater use of these drugs in the future, gastroenterologists should expect to be increasingly faced with gastrointestinal immune-related adverse events. Knowledge of these toxicities, as well as effective management algorithms, is essential to enable early diagnosis and treatment, decreasing morbidity and mortality. We reviewed the currently available literature on gastrointestinal toxicity induced by immune checkpoint inhibitors, namely the clinical features, diagnosis, and management.
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Affiliation(s)
- Marta Rocha
- Department of Gastroenterology, Hospital de Santo António/Centro Hospitalar do Porto, Porto, Portugal
| | - João Correia de Sousa
- Department of Gastroenterology, Hospital de Santo António/Centro Hospitalar do Porto, Porto, Portugal
| | - Marta Salgado
- Department of Gastroenterology, Hospital de Santo António/Centro Hospitalar do Porto, Porto, Portugal.,Institute of Biomedical Sciences Abel Salazar, Porto, Portugal
| | - António Araújo
- Department of Medical Oncology, Hospital de Santo António/Centro Hospitalar do Porto, Porto, Portugal.,Institute of Biomedical Sciences Abel Salazar, Porto, Portugal
| | - Isabel Pedroto
- Department of Gastroenterology, Hospital de Santo António/Centro Hospitalar do Porto, Porto, Portugal.,Institute of Biomedical Sciences Abel Salazar, Porto, Portugal
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Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors are monoclonal antibodies against the inhibitory, co-stimulatory molecules CTLA-4 and PD-1/PD-L1. Their use in oncology has been associated with frequent and diverse immune-related adverse events. In the digestive tract, such toxicity presents primarily as colonic inflammation, resembling inflammatory bowel disease (IBD). This review presents recent developments regarding the characteristics of checkpoint inhibitor colitis (CIC) and its relation to IBD. RECENT FINDINGS Several reports from patient cohorts with CIC have outlined its similarities and differences with IBD. Clinically and endoscopically, there is high overlap, including the negative prognostic significance of deep ulceration. Histologically, CIC may present as either acute colitis or demonstrate features of chronic damage, including IBD-like and lymphocytic colitis-like phenotypes. CIC immunopathogenesis appears to be associated with a predominance of mucosal Th1/Th17 effector responses, and may also be influenced by input from the gut microflora. Finally, current treatment of CIC is based on steroids and infliximab, although other biologics such as vedolizumab may also be effective. SUMMARY CIC represents a distinct form of colitis with characteristics reminiscent of IBD flares. Clarification of the mechanisms involved in its pathogenesis will greatly enhance our understanding and therapeutic management of immune-mediated colitides, including IBD.
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