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Kumar V, Montgomery ND, van Deventer HW, Whang YE. Waldenström macroglobulinemia with secondary pure red cell aplasia in a patient with metastatic castrate resistant prostate cancer receiving an immune checkpoint inhibitor: a case report. J Med Case Rep 2023; 17:220. [PMID: 37245043 DOI: 10.1186/s13256-023-03948-4] [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: 01/17/2022] [Accepted: 04/24/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Hypoproliferative anemia is a frequently encountered adverse event in cancer patients receiving immune checkpoint inhibitors (ICI). Secondary pure red cell aplasia (PRCA) is a rare but recognized immune related adverse event. With the burgeoning use of ICIs, the association of secondary PRCA with an underlying lymphoproliferative disorder is often overlooked. CASE PRESENTATION We report a case of a 67-year-old non-Hispanic Caucasian male with metastatic castrate resistant prostate cancer, who developed severe transfusion dependent anemia with reticulocytopenia while receiving treatment with olaparib and pembrolizumab. His bone marrow findings demonstrated erythroid hypoplasia, in addition to a CD5-negative, CD10-negative monotypic B-cell population and a somatic MYD88L265P mutation. With a presence of an IgM-paraprotein, he was diagnosed with Waldenström macroglobulinemia (WM) with secondary PRCA and treated with 6 cycles of bendamustine and rituximab. He achieved a complete response with this regimen and was transfusion independent. CONCLUSION In this case, underlying WM was uncovered through systematic investigation of anemia caused by ICI therapy. This report highlights the possibility of a lymphoproliferative disorder in patients with concerns for PRCA with prior ICI exposure. If identified, treating the underlying lymphoproliferative disorder is highly efficacious in the management of the secondary PRCA.
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Affiliation(s)
- Vaibhav Kumar
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Chapel Hill, NC, 27599-7305, USA
| | - Nathan D Montgomery
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hendrik W van Deventer
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Young E Whang
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Chapel Hill, NC, 27599-7305, USA.
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Shouman M, Goubran H, Seghatchian J, Burnouf T. Hematological toxicities of immune checkpoint inhibitors and the impact of blood transfusion and its microbiome on therapeutic efficacy and recipient's safety and survival outcome:A systematic narrative appraisal of where we are now! Transfus Apher Sci 2023; 62:103685. [PMID: 36870904 DOI: 10.1016/j.transci.2023.103685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Classically, patients with solid and hematologic malignancies have been treated with a combination of chemotherapy with or without a holistic targeted strategy using approved conventional therapy. While the evidence-based use of Immunomodulatory drugs and Immune checkpoint inhibitors (ICIs), including those targeting the PD-1, PD-L1 and CTLA-4, have reshaped the treatment paradigm for many malignant tumors and significantly stretched the life expectancy of patients, as for any interventional therapy, the rise in ICI applications, was associated with the observation of more immune-related hematological adverse events. Many of these patients require transfusion support during their treatment in line with precision transfusion. It has been presumed that transfusion-related immunomodulation (TRIM) and the microbiome can pose immunosuppressive effects on the recipients. Looking to the past and beyond and translating available data into practice in the evolving role of pharmaceutical therapy to ICI-receiving patients, we performed a narrative review of the literature on the immune-related hematological adverse events of ICIs, immunosuppressive mechanisms linked to blood product transfusions, as well as the detrimental impact of transfusions and its related microbiome on the sustained efficacy of ICIs and the patients' survival outcomes. Recent reports are pointing to the negative impact of transfusion on ICI response. Studies have concluded that packed RBC [PRBC] transfusions lead to an inferior progression-free and overall survival in patients with advanced cancer receiving ICIs, even after adjustments for other prognostic variables. The attenuation of the effectiveness of immunotherapy likely results from the immunosuppressive effects of PRBC transfusions. It is, therefore, wise to look retrospectively and prospectively at the impact of transfusion on ICI effects and adopt, in the interim, a restrictive transfusion strategy, if applicable, for those patients.
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Affiliation(s)
- Mohamed Shouman
- Department of Medical Oncology, National Cancer Institute, Cairo, Egypt; Saskatoon Cancer Centre, Saskatchewan, Canada
| | - Hadi Goubran
- Saskatoon Cancer Centre and College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Jerard Seghatchian
- International Consultancy in Blood Components Manufacturing/Quality/Safety, Apheresis Technologies, Quality Audit/Inspection and Innovative DDR Strategy, London, England, UK
| | - Thierry Burnouf
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan; International Ph.D. Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan.
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Immune checkpoint inhibitor-induced pure red cell aplasia: Case series and large-scale pharmacovigilance analysis. Int Immunopharmacol 2023; 114:109490. [PMID: 36459923 DOI: 10.1016/j.intimp.2022.109490] [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: 10/16/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Impressive advances in immunotherapy, especially immune checkpoint inhibitors (ICIs), have made great progress in treating multiple cancers. However, ICIs can also cause serious, even incurable, immune-related adverse events (irAEs), most often in patients with colitis, dermatitis, hepatitis, and thyroiditis. Rare autoimmune hematologic toxicities have been reported in the literature but are poorly described. Pure red cell aplasia (PRCA) induced by ICIs is a life-threatening autoimmune disease; however, only a few cases have been reported in the literature. OBJECTIVE To characterize and evaluate PRCA associated with different ICI regimens in a public database and to review the relevant literature. METHODS We described a case series of patients experiencing PRCA while on ICIs. We also mined the Food and Drug Administration's Adverse Event Reporting System (FAERS) and used reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and multi-item gamma Poisson shrinker (MGPS) algorithms to analyze the data of the suspected adverse events of PRCA induced by ICIs between January 2011 and June 2022. RESULTS Fifteen patients with PRCA events while on ICIs were included in our case series. In FAERS, a total of 41 individual case safety reports (ICSRs) with different ICI regimens were retrieved, among which 28 (68.3%) were related to monotherapy and three (7.3%) involved a fatal outcome. Signals of PRCA for all four ICI monotherapies (nivolumab, pembrolizumab, durvalumab, and atezolizumab) and ICI combination therapy (ipilimumab/nivolumab) were detected. Ipilimumab/nivolumab presented a higher reporting signal than nivolumab. CONCLUSIONS There is a significant reporting signal of PRCA with several ICI agents. Clinicians should be aware of and monitor this potentially fatal adverse event.
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Wilson NR, Lockhart JR, Garcia-Perdomo HA, Oo TH, Rojas-Hernandez CM. Management and Outcomes of Hematological Immune-related Adverse Events: Systematic Review and Meta-analysis. J Immunother 2022; 45:13-24. [PMID: 34469413 DOI: 10.1097/cji.0000000000000390] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
Data regarding clinical outcomes and management of hematological manifestations of immune checkpoint inhibition (ICI) is limited to case reports, series, and a few retrospective reviews. We aimed to determine the rate of response of hematological immune-related adverse events (irAEs) to immunosuppressive therapy. MEDLINE (OVID), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to the present day. Retrospective reports were included without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. The primary outcome of this study was the rate of response to immunosuppression. Eighty studies (14 case series and 66 individual case reports) were analyzed with a total of 135 patients with ICI-related hematological irAEs. Data analysis showed an average proportional response rate to immunosuppression among hematological irAE entities of 50% (range: 25%-70%). The heterogeneity index (I2) was 0% among reports within each entity. There is a wide spectrum of hematological manifestations to ICI therapy, and to date there is no large randomized-controlled trial data to evaluate the efficacy of treatment strategies for hematological irAEs. We found a variable overall response rate to immunosuppression therapy of around 50%, without statistically significant heterogeneity among different irAE types but significant differences among the different countries of publication. Future studies evaluating the optimal dose and duration of immunosuppressive agents for patients with hematological irAEs should be undertaken.
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Affiliation(s)
- Nathaniel R Wilson
- Department of Internal Medicine, The University of Texas McGovern Medical School
| | | | | | - Thein H Oo
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Rare haematologic and neurologic drug reactions from immune checkpoint inhibition in a responding patient with metastatic anorectal mucosal melanoma. Eur J Cancer 2021; 160:273-276. [PMID: 34862082 DOI: 10.1016/j.ejca.2021.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/30/2021] [Indexed: 11/22/2022]
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Gérard A, Romani S, Van-Obberghen E, Fresse A, Muzzone M, Parassol N, Boscagli A, Rocher F, Borchiellini D, Drici MD. Case Report: Successful Treatment of Steroid-Refractory Immune Checkpoint Inhibitor-Related Pure Red Cell Aplasia With Cyclosporin. Front Oncol 2020; 10:1760. [PMID: 32984061 PMCID: PMC7484737 DOI: 10.3389/fonc.2020.01760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/06/2020] [Indexed: 11/13/2022] Open
Abstract
Anemia associated with Immune checkpoint inhibitor (ICI) is usually hemolytic and regenerative. Cases of non-regenerative pure red cell aplasia are rare, and typically improve upon drug discontinuation and after corticotherapy. We herein report a case of nivolumab-related erythroblastopenia refractory to steroids in a melanoma patient that improved only after treatment with cyclosporin. Nivolumab had been well tolerated for 2 months after being introduced as an adjuvant treatment. Hemoglobin level then progressively decreased from 12.7 g/dl as baseline value to a nadir of 4.3 g/dL despite transfusion with a total of 29 packed red blood cells in 3 months. Extensive workup including repeated bone marrow examinations led to the diagnosis of pure red cell aplasia. Anemia persisted despite nivolumab discontinuation and over a month of corticotherapy, but improved dramatically 3 days after cyclosporin initiation and did not recur upon cyclosporin tapering. The patient remains cancer-free 9 months after nivolumab withdrawal. This case highlights the under-recognized risk of erythroblastopenia in patients treated with ICI and proves cyclosporin is a valid alternative for the treatment of steroid-refractory cases.
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Affiliation(s)
- Alexandre Gérard
- Pharmacovigilance, Department of Clinical Pharmacology, Pasteur Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France
| | - Serena Romani
- Pharmacovigilance, Department of Clinical Pharmacology, Pasteur Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France
| | - Elise Van-Obberghen
- Pharmacovigilance, Department of Clinical Pharmacology, Pasteur Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France
| | - Audrey Fresse
- Pharmacovigilance, Department of Clinical Pharmacology, Pasteur Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France
| | - Marine Muzzone
- Pharmacovigilance, Department of Clinical Pharmacology, Pasteur Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France
| | - Nadège Parassol
- Pharmacovigilance, Department of Clinical Pharmacology, Pasteur Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France
| | - Annick Boscagli
- Department of Medical Oncology, Centre Antoine Lacassagne, Université Côte d’Azur, Nice, France
| | - Fanny Rocher
- Pharmacovigilance, Department of Clinical Pharmacology, Pasteur Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France
| | - Delphine Borchiellini
- Department of Medical Oncology, Centre Antoine Lacassagne, Université Côte d’Azur, Nice, France
| | - Milou-Daniel Drici
- Pharmacovigilance, Department of Clinical Pharmacology, Pasteur Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France
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