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Kitano M, Honda T, Hikita E, Masuo M, Miyazaki Y, Kobayashi M. Delayed immune-related adverse events in long-responders of immunotherapy: a single-center experience. Asia Pac J Clin Oncol 2024; 20:463-471. [PMID: 38608154 DOI: 10.1111/ajco.14059] [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: 09/25/2023] [Revised: 01/31/2024] [Accepted: 03/11/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Immune-checkpoint inhibitors (ICIs) often cause immune-related adverse events (irAEs). The spectrum of irAEs and their managements has been partially clarified, however the knowledge on time-course of irAEs is not well understood. METHODS A retrospective study based on the medical record was performed. The study subjects were consisting of patients with various types of solid tumors for whom ICIs (nivolumab, pembrolizumab, durvalumab, atezolizumab, nivolumab plus ipilimumab) were used between April 2016 and October 2021. We focused on irAEs developed more than 1-year after commencement ICIs (delayed irAE group) and compared with irAEs developed within 1-year (non-delayed irAE group) in terms of types and severity of irAEs. RESULTS A total of 336 patients were enrolled in the study. Eighty-eight patients (26.2%) developed irAEs and 248 did not. Most of the patients developing irAEs were treated using PD-L1/PD-1 inhibitors. Eighty-one patients (24.1%) in non-delayed irAE group and 7 patients (2.1%) in delayed irAE group developed irAEs. The median onset of irAEs in the delayed irAE group was 18.6 months (range: 13.5-24.3). The types of irAEs observed in delayed irAE group were dermatitis (2 cases), pneumonitis (2 cases), nephritis (1 case), arthritis (1 case), and gastritis (1 case). The severity of irAEs was almost mild (≤G2), but one patient (.3%) developed G3 nephritis. CONCLUSION PD-L1/PD-1 inhibitors frequently caused various irAEs but their severities were mostly tolerable. Few patients developed delayed irAE with mild toxities.
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Affiliation(s)
- Masatake Kitano
- Department of Respiratory Medicine, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Takayuki Honda
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Eri Hikita
- Department of Pharmacy, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Masahiro Masuo
- Department of Respiratory Medicine, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Masayoshi Kobayashi
- Department of Respiratory Medicine, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
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Karaviti D, Kani ER, Karaviti E, Gerontiti E, Michalopoulou O, Stefanaki K, Kazakou P, Vasileiou V, Psaltopoulou T, Paschou SA. Thyroid disorders induced by immune checkpoint inhibitors. Endocrine 2024; 85:67-79. [PMID: 38345684 PMCID: PMC11246261 DOI: 10.1007/s12020-024-03718-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/30/2024] [Indexed: 07/14/2024]
Abstract
Immune checkpoint inhibitors (ICIs) are a revolutionary class of drugs that powerfully contribute to cancer therapy by harnessing the immune system to fight malignancies. However, their successful use as anti-cancer drugs is accompanied by a wide spectrum of immune-related adverse effects (irAEs), including endocrinopathies. Among them, thyroid dysfunction stands out as one of the most common endocrinopathies induced by ICI therapy and surfaces as a prominent concern. Destructive thyroiditis is the pathophysiological basis shared by the most common patterns of thyrotoxicosis followed by hypothyroidism and isolated hypothyroidism. Diagnostic approach is guided by clinical manifestation, laboratory evaluation and imaging modalities. Treatment approaches range from the substitution of levothyroxine to the utilization of beta blockers, depending on the extent of thyroid dysfunction's severity. While the medical community is dealing with the evolution and complexities of immunotherapy, recognizing and effectively managing ICI-induced thyroid dysfunction emerged as crucial for enhancing patient safety and achieving improved outcomes. The aim of this review is to navigate the significance of ICI-induced thyroid dysfunction unraveling the various patterns, underlying mechanisms, diagnostic approaches, and treatment strategies. It, also, highlights the impact of various factors such as cancer subtype, ICI dosage, age, and genetic susceptibility on the risk of experiencing dysfunction.
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Affiliation(s)
- Dimitra Karaviti
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni-Rafaela Kani
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftheria Karaviti
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Gerontiti
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Olympia Michalopoulou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Stefanaki
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Kazakou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Theodora Psaltopoulou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
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Feng Y, He C, Liu C, Shao B, Wang D, Wu P. Exploring the Complexity and Promise of Tumor Immunotherapy in Drug Development. Int J Mol Sci 2024; 25:6444. [PMID: 38928150 PMCID: PMC11204037 DOI: 10.3390/ijms25126444] [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: 04/23/2024] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Cancer represents a significant threat to human health, and traditional chemotherapy or cytotoxic therapy is no longer the sole or preferred approach for managing malignant tumors. With advanced research into the immunogenicity of tumor cells and the growing elderly population, tumor immunotherapy has emerged as a prominent therapeutic option. Its significance in treating elderly cancer patients is increasingly recognized. In this study, we review the conceptual classifications and benefits of immunotherapy, and discuss recent developments in new drugs and clinical progress in cancer treatment through various immunotherapeutic modalities with different mechanisms. Additionally, we explore the impact of immunosenescence on the effectiveness of cancer immunotherapy and propose innovative and effective strategies to rejuvenate senescent T cells.
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Affiliation(s)
| | | | | | | | - Dong Wang
- School of Basic Medical Sciences and State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China; (Y.F.); (C.H.); (C.L.); (B.S.)
| | - Peijie Wu
- School of Basic Medical Sciences and State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China; (Y.F.); (C.H.); (C.L.); (B.S.)
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Watanabe S, Tamura Y, Oba K, Kitayama S, Sato M, Kodera R, Toyoshima K, Chiba Y, Araki A. Hypopituitarism with secondary adrenocortical insufficiency and arginine vasopressin deficiency due to hypophysitis after COVID-19 vaccination: a case report. BMC Endocr Disord 2024; 24:71. [PMID: 38769570 PMCID: PMC11103972 DOI: 10.1186/s12902-024-01582-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/16/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Although vaccination against coronavirus disease (COVID-19) has several side effects, hypopituitarism due to hypophysitis has rarely been reported. CASE PRESENTATION An 83-year-old healthy woman, who had received her fourth COVID-19 vaccine dose 2 days before admission, presented to the emergency department with difficulty moving. On examination, impaired consciousness (Glasgow Coma Scale: 14) and fever were observed. Computed tomography and magnetic resonance imaging of the head revealed swelling from the sella turcica to the suprasellar region. Her morning serum cortisol level was low (4.4 μg/dL) and adrenocorticotropic hormone level was normal (21.6 pg/mL). Central hypothyroidism was also suspected (thyroid stimulating hormone, 0.46 μIU/mL; free triiodothyronine, 1.86 pg/mL; free thyroxine, 0.48 ng/dL). Secondary adrenocortical insufficiency, growth hormone deficiency, delayed gonadotropin response, and elevated prolactin levels were also observed. After administration of prednisolone and levothyroxine, her consciousness recovered. On the 7th day of admission, the patient developed polyuria, and arginine vasopressin deficiency was diagnosed using a hypertonic saline test. On the 15th day, the posterior pituitary gland showed a loss of high signal intensity and the polyuria resolved spontaneously. On the 134th day, the corticotropin-releasing hormone loading test showed a normal response; however, the thyrotropin-releasing hormone stimulation test showed a low response. The patient's disease course was stable with continued thyroid and adrenal corticosteroid supplementation. CONCLUSIONS Herein, we report a rare case of anterior hypopituitarism and arginine vasopressin deficiency secondary to hypophysitis following COVID-19 vaccination.
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Affiliation(s)
- So Watanabe
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Yoshiaki Tamura
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan.
| | - Kazuhito Oba
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Saori Kitayama
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Motoya Sato
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Remi Kodera
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Kenji Toyoshima
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Yuko Chiba
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Atsushi Araki
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakaecho, Itabashi-Ku, Tokyo, 173-0015, Japan
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Basek A, Jakubiak GK, Cieślar G, Stanek A. Life-Threatening Endocrinological Immune-Related Adverse Events of Immune Checkpoint Inhibitor Therapy. Cancers (Basel) 2023; 15:5786. [PMID: 38136332 PMCID: PMC10742092 DOI: 10.3390/cancers15245786] [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: 11/01/2023] [Revised: 11/29/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Malignant neoplasms are currently one of the leading causes of morbidity and mortality worldwide, posing a major public health challenge. However, recent advances in research in cancer biology and immunity have led to the development of immunotherapy, which is now used on an everyday basis in cancer treatment in addition to surgical treatment, classical cytostatics, and radiotherapy. The efficacy of immunotherapy has promoted the great popularity of this treatment among patients, as well as significant research interest. The increasing number of patients being treated with immunotherapy not only reassures physicians of the efficacy of this technique but also shows the wide spectrum of side effects of this therapy, which has not been considered before. Immune-related adverse events may affect many systems and organs, such as digestive, cardiovascular, respiratory, skin, or endocrine organs. Most complications have a mild or moderate course, but there are life-threatening manifestations that are essential to be aware of because if they are not properly diagnosed and treated on time, they can have fatal consequences. The purpose of this paper was to present the results of a literature review on the current state of knowledge on life-threatening endocrine side effects (such as adrenal crisis, thyroid storm, myxoedema crisis, diabetic ketoacidosis, and severe hypocalcaemia) of immune checkpoint inhibitors to provide information on symptoms, diagnostics, and management strategies.
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Affiliation(s)
- Aleksandra Basek
- Student Research Group, Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland;
| | - Grzegorz K. Jakubiak
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
| | - Grzegorz Cieślar
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
| | - Agata Stanek
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
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Huang W, Liu Y, Li M, Xue Y, Bao W, Guo Y. Sintilimab-related diabetes mellitus and psoriasis: A case report and literature review. Medicine (Baltimore) 2023; 102:e35946. [PMID: 37960733 PMCID: PMC10637498 DOI: 10.1097/md.0000000000035946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/13/2023] [Indexed: 11/15/2023] Open
Abstract
RATIONALE With the popularity of ICIs in different oncology treatments, immune-related adverse events have raised concerns, mostly occurring in skin and endocrine gland injury. This disease involves different organ systems and presents with a variety of clinical manifestations. Most patients with immune checkpoint inhibitor-induced type 1 diabetes are reported to have no combination of autoimmune disease. We report a case of Sintilimab-related diabetes mellitus and psoriasis. PATIENT CONCERNS We report a case of a 65-year-old female with Sintilimab-related diabetes mellitus and psoriasis. DIAGNOSIS The patient treated with anti-programmed cell death protein 1 (Sintilimab) for 4 cycles. The patient presented with inexplicable bouts of nausea and vomiting, accompanied by chest discomfort and a feeling of breathlessness, prompting their admission to the local hospital. The initial assessment upon admission revealed an abrupt elevation in blood glucose levels, alongside normal ketone levels, lactic acidosis, and hyperuricemia. A comprehensive regimen was provided to regulate glucose levels and address the symptoms, resulting in notable improvement and subsequent discharge. Regrettably, the patient's personal decision to discontinue medication for a single day led to the emergence of acute ketoacidosis, coupled with a recurrence of psoriasis vulgaris. Consequently, readmission became necessary. Based on the patient's medical history and diabetes antibody testing, the diagnosis of immune checkpoint inhibitor induced diabetes mellitus has been confidently established. INTERVENTIONS The patient ceased treatment with Sintilimab and was initiated on insulin therapy for glycemic control, alongside symptomatic management for psoriasis. Upon stabilization of the condition, long-term administration of exogenous insulin was implemented as a substitute treatment. OUTCOME Outside of the hospital, insulin therapy effectively maintained stable blood glucose levels, and there were no further episodes of psoriasis flare-ups. LESSON The clinical manifestations of immune checkpoint inhibitor induced diabetes mellitus are variable, and in this case the patient presented with unique primary symptoms. Therefore, it is crucial to accumulate relevant cases, understand the different clinical presentations and identify the underlying mechanisms of the disease. This will provide further evidence for early therapeutic intervention in similar patients in the future.
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Affiliation(s)
- Wenying Huang
- School of Clinical Medicine, Weifang Medical University, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Yan Liu
- School of Clinical Medicine, Weifang Medical University, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Min Li
- School of Clinical Medicine, Weifang Medical University, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Yuan Xue
- School of Clinical Medicine, Weifang Medical University, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Weichao Bao
- School of Clinical Medicine, Weifang Medical University, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Ying Guo
- School of Clinical Medicine, Weifang Medical University, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
- Department of Endocrinology and Metabolic Diseases, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
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Ruggeri RM, Spagnolo CC, Alibrandi A, Silvestris N, Cannavò S, Santarpia M. Predictors of thyroid adverse events during cancer immunotherapy: a real-life experience at a single center. J Endocrinol Invest 2023; 46:2399-2409. [PMID: 37076759 DOI: 10.1007/s40618-023-02096-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/07/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Thyroid dysfunction is among the most common immune-related adverse events (irAEs) of immune checkpoint inhibitors (ICIs) therapy. Data regarding potential predictors of the development of thyroid irAEs are still limited and sometimes conflicting. PATIENTS AND METHODS We assessed potential risk factors and clinical outcomes associated with the onset of thyroid irAEs in a cohort of patients with different types of cancer treated with ICIs at a single center. Clinical and biochemical data, including thyroid function tests and autoantibodies at baseline and during treatment, were collected, and the onset of thyroid irAEs was recorded. Patients with thyroid dysfunction and/or under levothyroxine therapy before starting ICI were excluded. RESULTS 110 patients (80 M, 30 F, aged 32-85 years; 56.4% non-small-cell lung cancer, 87% treated with anti-PD-1) with complete information were included in the study. Among them, 32 (29%) developed thyroid irAEs during ICIs therapy. Primary hypothyroidism was the most common irAEs, occurring in 31 patients (28.18% of the whole cohort), including 14 patients who experienced a transient thyrotoxicosis. About 60% of irAEs occurred within the first 8 weeks of therapy. At multivariate analysis, anti-thyroid autoantibodies positivity at baseline (OR 18.471, p = 0.022), a pre-existing (autoimmune and non-autoimmune) thyroid disorder (OR 16.307, p < 0.001), and a family history of thyroid diseases (OR = 9.287, p = 0.002) were independent predictors of the development of thyroid irAEs. CONCLUSION Our data confirm the high frequency of thyroid dysfunctions (mostly hypothyroidism) during ICIs, and provide data on valuable predictors of thyroid toxicities that may help clinicians in identifying patients at risk for developing irAEs.
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Affiliation(s)
- R M Ruggeri
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy.
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy.
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy.
- Endocrine Unit, Department of Clinical and Experimental Medicine, "Gaetano Martino" University Hospital, 98125, Messina, Italy.
| | - C C Spagnolo
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
| | - A Alibrandi
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
| | - N Silvestris
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
| | - S Cannavò
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
| | - M Santarpia
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
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Huo L, Wang C, Ding H, Shi X, Shan B, Zhou R, Liang P, Hou J. Severe thyrotoxicosis induced by tislelizumab: a case report and literature review. Front Oncol 2023; 13:1190491. [PMID: 37849819 PMCID: PMC10578961 DOI: 10.3389/fonc.2023.1190491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/31/2023] [Indexed: 10/19/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have made significant breakthroughs in the treatment of a variety of malignancies. As its use increases, the unique immune-mediated toxicity profile of ICls are becoming apparent. We report a case of immune-related endocrine adverse events (irAE) in a patient with hepatocellular carcinoma treated with anti-programmed cell death protein 1 (PD-1) (tislelizumab). Although many irAEs have been reported, few cases of severe thyrotoxicosis have been described after immunotherapy in the literature. We present the case of a 49-year-old male who experienced a Grade 3 tislelizumab-related adverse reaction according to Common Terminology Criteria for Adverse Events (CTCAE5.0) and received methylprednisolone, thiamazole, and levothyroxine sodium tablets. Early identification of irAEs, risk factors, regular monitoring, use of steroids and/or immunoglobulins, and adjuvant supportive care are critical to the clinical prognosis of patients. It should be underlined that the tumor benefits of ICI therapy outweigh the risks associated with ICI-induced endocrine disorders, and ICI treatment should not be stopped or delayed except in rare cases (adrenal crisis, severe thyrotoxicosis). The familiarity of healthcare professionals with irAEs of the thyroid when thyrotoxicosis occurs is important to facilitate an effective diagnosis and appropriate treatment of this increasingly common thyroid disorder.
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Affiliation(s)
- Liman Huo
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chao Wang
- Department of Hepatobiliary Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Haixia Ding
- Department of Endocrinology, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuelian Shi
- Department of Pain, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bin Shan
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ruoying Zhou
- Department of Pharmacy, Anguo Hospital, Baoding, China
| | - Ping Liang
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Juan Hou
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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9
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Alqahtani A, Alghamdi L, Alghassab A, Almalki M. Immune Checkpoint Inhibitor-Induced Endocrine Adverse Events in Cancer Patients at a Tertiary Care Center in Saudi Arabia. Cureus 2023; 15:e44296. [PMID: 37779728 PMCID: PMC10533951 DOI: 10.7759/cureus.44296] [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: 08/28/2023] [Indexed: 10/03/2023] Open
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) are approved to treat several types of cancer, but they may cause an exaggerated immune response. This can lead to immune-related adverse events such as endocrinopathies, which mostly affect the thyroid and pituitary gland. METHODS A retrospective analysis was conducted on 125 cancer patients receiving ICIs (pembrolizumab, nivolumab, and ipilimumab) between July 2018 and July 2022. The study reviewed hormone test results and the clinical perspectives of patients to identify and characterize endocrine adverse events associated with ICI therapy in cancer patients. RESULTS Among the 125 patients who were examined, a total of 26 patients (20.8%) encountered endocrine-related adverse effects. A total of 25 patients had thyroid dysfunction. Hypophysitis was detected in a limited cohort of two patients, along with primary hypothyroidism. A case of newly diagnosed type 1 diabetes mellitus was seen in a single patient. None of the patients had primary adrenal insufficiency or parathyroid dysfunction. The administration of pembrolizumab was shown to be associated with the occurrence of thyroid dysfunction in 18 cases, as well as two cases of hypophysitis. In contrast, nivolumab was responsible for inducing thyroid dysfunction in four cases. The remaining occurrences were attributable to combination treatment. CONCLUSION The study found an increased risk of thyroid dysfunction among cancer patients receiving ICIs, while pituitary dysfunction was a less frequent adverse effect. It is recommended that an endocrine assessment be conducted before therapy initiation and periodically afterward.
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Affiliation(s)
- Ali Alqahtani
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, SAU
| | - Lamia Alghamdi
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, SAU
| | | | - Mussa Almalki
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, SAU
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Coniac S, Costache Outas MC, Pirvu EE, Patru RI, Gainariu E, Aldea C, Iorga PG, Ambroci M, Liscu HD, Miron AI, Badiu C. Challenges and Limitations of Endocrine Toxicity Evaluation in Non-Small Cell Lung Cancer Patients Treated with Immunotherapy-Retrospective Study from a Tertiary-Level Hospital in Romania. Diagnostics (Basel) 2023; 13:diagnostics13101788. [PMID: 37238273 DOI: 10.3390/diagnostics13101788] [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: 04/02/2023] [Revised: 05/03/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: The endocrine system has become a prominent target to autoimmune damage during treatment with immune checkpoint inhibitors (ICIs) in cancer patients. Real-world data regarding endocrine immune-related adverse events (irAEs) are needed to explore their impact in cancer patients. An analysis was conducted to evaluate endocrine irAEs caused by ICIs, besides the challenges and limitations of daily medical practice in oncology in Romania. (2) Methods: This was a retrospective cohort study of lung cancer patients treated with ICIs at Coltea Clinical Hospital, Bucharest, Romania, from 1 November 2017 to 30 November 2022. Endocrine irAEs were identified through endocrinological assessment and were distinguished as any occurring endocrinopathy during treatment with ICIs and related to immunotherapy. Descriptive analyses were performed. (3) Results: Of 310 cancer patients treated with ICIs, we identified 151 with lung cancer. From this cohort, 109 NSCLC patients qualified for baseline endocrine estimation and 13 patients (11.9%) developed endocrine irAEs, such as hypophysitis (4.5%), thyroid disorder (5.5%) and primary adrenal insufficiency (1.8%), with one or more endocrine glands being affected. There might be a correlation between endocrine irAEs and duration of ICI treatment. (4) Conclusions: Early diagnosis and adequate management of endocrine irAEs may be challenging in lung cancer patients. A high incidence of endocrine irAEs is expected with the growing use of ICIs, and because not all endocrine events are immune-related, cooperation between oncologists and endocrinologists is crucial in the management of these patients. More data are needed to confirm the correlation between endocrine irAEs and the efficacy of ICIs.
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Affiliation(s)
- Simona Coniac
- Department of Medical Oncology, Coltea Clinical Hospital, 030167 Bucharest, Romania
- Department of Endocrinology, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | | | - Edvina-Elena Pirvu
- Department of Medical Oncology, Coltea Clinical Hospital, 030167 Bucharest, Romania
| | - Raluca-Ileana Patru
- Department of Medical Oncology, Coltea Clinical Hospital, 030167 Bucharest, Romania
| | - Estera Gainariu
- Department of Medical Oncology, Coltea Clinical Hospital, 030167 Bucharest, Romania
| | - Ciprian Aldea
- Department of Medical Oncology, Coltea Clinical Hospital, 030167 Bucharest, Romania
| | - Polixenia Georgeta Iorga
- Department of Medical Oncology, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Mihaela Ambroci
- Department of Medical Oncology, Hôpital Paul-Brousse, 94804 Villejuif, France
| | - Horia-Dan Liscu
- Department of Radiotherapy, Coltea Clinical Hospital, 030167 Bucharest, Romania
- Discipline of Oncological Radiotherapy and Medical Imaging, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Andreea-Iuliana Miron
- Department of Radiotherapy, Coltea Clinical Hospital, 030167 Bucharest, Romania
- Discipline of Oncological Radiotherapy and Medical Imaging, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Corin Badiu
- Department of Endocrinology, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Endocrinology, "C.I. Parhon" National Institute of Endocrinology, 011863 Bucharest, Romania
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11
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Cardona Z, Sosman JA, Chandra S, Huang W. Endocrine side effects of immune checkpoint inhibitors. Front Endocrinol (Lausanne) 2023; 14:1157805. [PMID: 37251665 PMCID: PMC10210589 DOI: 10.3389/fendo.2023.1157805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/05/2023] [Indexed: 05/31/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have increasingly been the mainstay of treatment for numerous malignancies. However, due to their association with autoimmunity, ICIs have resulted in a variety of side effects that involve multiple organs including the endocrine system. In this review article, we describe our current understanding of the autoimmune endocrinopathies as a result of the use of ICIs. We will review the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of the most commonly encountered endocrinopathies, including thyroiditis, hypophysitis, Type 1 diabetes, adrenalitis, and central diabetes insipidus.
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Affiliation(s)
- Zulma Cardona
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jeffrey A. Sosman
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sunandana Chandra
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Wenyu Huang
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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12
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Naidoo J, Murphy C, Atkins MB, Brahmer JR, Champiat S, Feltquate D, Krug LM, Moslehi J, Pietanza MC, Riemer J, Robert C, Sharon E, Suarez-Almazor ME, Suresh K, Turner M, Weber J, Cappelli LC. Society for Immunotherapy of Cancer (SITC) consensus definitions for immune checkpoint inhibitor-associated immune-related adverse events (irAEs) terminology. J Immunother Cancer 2023; 11:jitc-2022-006398. [PMID: 37001909 PMCID: PMC10069596 DOI: 10.1136/jitc-2022-006398] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/03/2023] Open
Abstract
Immune-related adverse events (irAEs) associated with immune checkpoint inhibitor (ICI) therapy may vary substantially in their clinical presentation, including natural history, outcomes to treatment, and patterns. The application of clinical guidelines for irAE management can be challenging for practitioners due to a lack of common or consistently applied terminology. Furthermore, given the growing body of clinical experience and published data on irAEs, there is a greater appreciation for the heterogeneous natural histories, responses to treatment, and patterns of these toxicities, which is not currently reflected in irAE guidelines. Furthermore, there are no prospective trial data to inform the management of the distinct presentations of irAEs. Recognizing a need for uniform terminology for the natural history, response to treatment, and patterns of irAEs, the Society for Immunotherapy of Cancer (SITC) convened a consensus panel composed of leading international experts from academic medicine, industry, and regulatory agencies. Using a modified Delphi consensus process, the expert panel developed clinical definitions for irAE terminology used in the literature, encompassing terms related to irAE natural history (ie, re-emergent, chronic active, chronic inactive, delayed/late onset), response to treatment (ie, steroid unresponsive, steroid dependent), and patterns (ie, multisystem irAEs). SITC developed these definitions to support the adoption of a standardized vocabulary for irAEs, which will have implications for the uniform application of irAE clinical practice guidelines and to enable future irAE clinical trials.
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Affiliation(s)
- Jarushka Naidoo
- Oncology, Beaumont RCSI Cancer Centre, Dublin, Ireland
- RCSI university of Health Sciences, Beaumont RSCI Cancer Centre, Dublin, Ireland
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Catherine Murphy
- Department of Oncology, St Vincents University Hospital, Dublin, Ireland
- Department of Oncology, Beaumont Hospital, Beaumont RCSI Cancer Centre, Dublin, Ireland
| | - Michael B Atkins
- Oncology, Georgetown University, Washington, District of Columbia, USA
| | - Julie R Brahmer
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | | | | | | | | | | | - Joanne Riemer
- Oncology, Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Caroline Robert
- Institut Gustave-Roussy, Villejuif, France
- Paris-Saclay University, Gif-sur-Yvette, France
| | - Elad Sharon
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Karthik Suresh
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Michelle Turner
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Jeffrey Weber
- Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Laura C Cappelli
- Division of Rheumatology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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13
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Ishay A, Shacham EC. Central diabetes insipidus: a late sequela of BNT162b2 SARS-CoV-2 mRNA vaccine? BMC Endocr Disord 2023; 23:47. [PMID: 36810011 PMCID: PMC9945387 DOI: 10.1186/s12902-023-01296-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 02/08/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND The development of an effective vaccine is a powerful tool to contain the global spread of coronavirus disease 2019 (COVID-19). Still, it raises potential safety concerns about the subsequent enhancement of associated immunopathology. Increasing evidence shows that the endocrine system, including the hypophysis, may be involved in COVID-19. Moreover, occasional but increasing reports of endocrine disorders involving the thyroid have been reported after the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Among them, a few cases encompass the pituitary. Here we report a rare case of central diabetes insipidus following SARS-CoV-2 vaccination. CASE PRESENTATION We report a 59-year-old female patient with a 25-year history of Crohn's disease in long-term remission, who presented with sudden onset of polyuria eight weeks after administration of an mRNA SARS-CoV-2 vaccination. Laboratory evaluation was consistent with isolated central diabetes insipidus. Magnetic resonance imaging displayed involvement of the infundibulum and the posterior hypophysis. Eighteen months after the vaccination, she is still under desmopressin treatment and had stable pituitary stalk thickening on magnetic resonance imaging. Although Crohn's disease-associated hypophysitis has been reported, it is scarce. In the absence of other recognizable causes of hypophysitis, we believe the involvement of the hypophysis in our patient may have been triggered by the SARS-CoV-2 vaccine. CONCLUSIONS We report a rare case of central diabetes insipidus potentially associated with SARS-CoV-2 mRNA vaccination. Further studies are needed to understand better the mechanisms underlying autoimmune endocrinopathies development in the context of COVID-19 infection and SARS-CoV-2 vaccination.
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Affiliation(s)
- Avraham Ishay
- Endocrinology Unit, HaEmek Medical Center, Yitzhak Rabin Av. 21, 18101 Afula, Israel
- Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel
| | - Elena Chertok Shacham
- Endocrinology Unit, HaEmek Medical Center, Yitzhak Rabin Av. 21, 18101 Afula, Israel
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14
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Valerio L, Giani C, Matrone A, Pontillo-Contillo B, Minaldi E, Agate L, Molinaro E, Elisei R. Adrenal insufficiency in thyroid cancer patients treated with tyrosine kinase inhibitors and detected by ACTH stimulation test. J Endocrinol Invest 2023:10.1007/s40618-023-02025-3. [PMID: 36809657 DOI: 10.1007/s40618-023-02025-3] [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: 08/09/2022] [Accepted: 01/25/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE Advanced thyroid cancer patients treated with tyrosine kinase inhibitors (TKI) can develop several adverse events (AEs), including adrenal insufficiency (AI). METHODS We studied 55 patients treated with TKI for radioiodine-refractory or medullary thyroid cancer. The adrenal function was evaluated during follow-up by performing serum basal ACTH, and basal and ACTH-stimulated cortisol. RESULTS Twenty-nine/55 (52.7%) patients developed subclinical AI during TKI treatment as demonstrated by a blunted cortisol response to ACTH stimulation. All cases showed normal values of serum sodium, potassium and blood pressure. All patients were immediately treated, and none showed an overt AI. Cases with AI were all negative for adrenal antibodies and did not show any adrenal gland alteration. Other causes of AI were excluded. The onset time of the AI, as measured in the subgroup with a first negative ACTH test, was < 12 months in 5/9 (55.6%), between 12 and 36 months in 2/9 (22.2%) and > 36 months in 2/9 (22.2%) cases. In our series, the only prognostic factor of AI was the elevated, although moderate, basal level of ACTH when the basal and stimulated cortisol were still normal. The glucocorticoid therapy improved fatigue in most patients. CONCLUSIONS Subclinical AI can be developed in > 50% of advanced thyroid cancer patients treated with TKI. This AE can develop in a wide period ranging from < 12 to > 36 months. For this reason, AI must be looked for throughout the follow-up to be early recognized and treated. A periodic ACTH stimulation test, every 6-8 months, can be helpful.
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Affiliation(s)
- L Valerio
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - C Giani
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - A Matrone
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - B Pontillo-Contillo
- Diagnostic and Interventional Radiology Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - E Minaldi
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - L Agate
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - E Molinaro
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - R Elisei
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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15
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Prognostic Significance of the Severity of Immune-Related Adverse Events in Advanced Cancer Patients Treated with PD-1/PD-L1 Inhibitors: A Real-World Data Analysis. Target Oncol 2023; 18:147-158. [PMID: 36515782 DOI: 10.1007/s11523-022-00936-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is limited evidence regarding immune-related adverse events (irAEs) in Asian cancer patients treated with antibodies directed against programmed cell death-1 (PD-1) or programmed cell death-ligand 1 (PD-L1). OBJECTIVE This study aimed to investigate the clinical patterns and prognostic significance of grade 1-2 and grade ≥ 3 irAEs by PD-1/PD-L1 inhibitors in cancer patients using real-world clinical data. PATIENTS AND METHODS We conducted a retrospective study of cancer patients who received pembrolizumab, nivolumab, or atezolizumab at a tertiary hospital in South Korea. Incidence, time to onset, and grade 1-2 and grade ≥ 3 irAE risk factors were analyzed from medical records. The association of irAE severity with progression-free survival (PFS) and prognostic factors for PFS were evaluated. RESULTS Among a total of 431 patients, irAEs occurred in 45.2%, and 9.5% were grade ≥ 3 irAEs. There were no significant differences in the median time to onset based on severity. Risk factors for the development of grade ≥ 3 irAEs were the presence of autoimmune disorders or diabetes mellitus. The median PFS was significantly different at 13.20, 9.00 and 4.17 months for the grade 1-2, grade ≥ 3, and no irAE groups, respectively. An increase in administration cycles was associated with a reduced risk of progression in patients with grade 1-2 and grade ≥ 3 irAEs. CONCLUSIONS The development of grade ≥ 3 irAEs was affected by comorbidities and associated with improved PFS compared with those without irAEs. Our findings identified the real-world epidemiology, risk factors, and prognostic significance of irAEs, which may guide treatment decisions of PD-1/PD-L1 inhibitors.
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16
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Spagnolo CC, Giuffrida G, Cannavò S, Franchina T, Silvestris N, Ruggeri RM, Santarpia M. Management of Endocrine and Metabolic Toxicities of Immune-Checkpoint Inhibitors: From Clinical Studies to a Real-Life Scenario. Cancers (Basel) 2022; 15:cancers15010246. [PMID: 36612243 PMCID: PMC9818218 DOI: 10.3390/cancers15010246] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/22/2022] [Accepted: 12/24/2022] [Indexed: 01/03/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the therapeutic landscape of solid tumors. However, although ICIs are better tolerated than conventional chemotherapy, their use is associated with a peculiar toxicity profile, related to the enhancement of the immune response, affecting several organs. Among immune-related adverse events (irAEs), up to 10% involve the endocrine system. Most of them are represented by thyroid disorders (hypothyroidism and hyperthyroidism), mainly correlated to the use of anti-PD-1 and/or anti-PD-L1 agents. Less common endocrine irAEs include hypophysitis, adrenalitis, and metabolic irAEs. A deeper understanding of endocrine toxicities is a critical goal for both oncologists and endocrinologists. A strict collaboration between these specialists is mandatory for early recognition and proper treatment of these patients. In this review we will provide a comprehensive overview of endocrine and metabolic adverse events of ICIs, with particular interest in the pathogenesis, predisposing factors and clinical presentation of these irAEs, and their impact on clinical outcomes of patients. Furthermore, we will summarize the most recent studies and recommendations on the clinical approach to immune-related endocrinopathies with the purpose to optimize the diagnostic algorithm, and to help both oncologists and endocrinologists to improve the therapeutic management of these unique types of irAEs, in a real-life scenario.
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Affiliation(s)
- Calogera Claudia Spagnolo
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy
| | - Giuseppe Giuffrida
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV, University of Messina, 98125 Messina, Italy
| | - Salvatore Cannavò
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV, University of Messina, 98125 Messina, Italy
| | - Tindara Franchina
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy
| | - Nicola Silvestris
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy
| | - Rosaria Maddalena Ruggeri
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV, University of Messina, 98125 Messina, Italy
| | - Mariacarmela Santarpia
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy
- Correspondence:
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Ling SP, Ming LC, Dhaliwal JS, Gupta M, Ardianto C, Goh KW, Hussain Z, Shafqat N. Role of Immunotherapy in the Treatment of Cancer: A Systematic Review. Cancers (Basel) 2022; 14:5205. [PMID: 36358624 PMCID: PMC9655090 DOI: 10.3390/cancers14215205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 01/18/2024] Open
Abstract
Tremendous progress has been made in cancer research over the years, and, as a result, immunotherapy has emerged as an important therapy for the treatment of cancer, either as a stand-alone treatment or in conjunction with other cancer therapies. Immunotherapy has demonstrated encouraging outcomes and offers a viable strategy for not only enhancing the quality of life but also dramatically boosting the overall survival rate of cancer patients. The objective of this systematic review was to assess the efficacy of immunotherapy in the treatment of cancer. Databases such as PubMed and Science Direct were searched from their inception until September 2021, using the following keywords: cancer immunotherapy, cancer recurrence, cancer treatment options, and cancer therapies. The systematic review was conducted in accordance with the PRISMA protocol. There were a total of 599 articles; however, after applying the inclusion and exclusion criteria, the final review ended up with 34 publications. In conclusion, the studies have demonstrated that immunotherapy is a viable alternative treatment option for patients with recurrent or metastatic cancer, since the overall survival rate and progression-free survival rate were shown to be successful.
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Affiliation(s)
- Sia Pei Ling
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong BE1410, Brunei
| | - Long Chiau Ming
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong BE1410, Brunei
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia
| | - Jagjit Singh Dhaliwal
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong BE1410, Brunei
| | - Madhu Gupta
- School of Pharmaceutical Sciences, Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi 110017, India
| | - Chrismawan Ardianto
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia
| | - Khang Wen Goh
- Faculty of Data Science and Information Technology, INTI International University, Nilai 71800, Malaysia
| | - Zahid Hussain
- Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia
| | - Naeem Shafqat
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong BE1410, Brunei
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Clinical Presentation of Immune-Related Endocrine Adverse Events during Immune Checkpoint Inhibitor Treatment. Cancers (Basel) 2022; 14:cancers14112687. [PMID: 35681667 PMCID: PMC9179613 DOI: 10.3390/cancers14112687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/14/2022] [Accepted: 05/26/2022] [Indexed: 02/01/2023] Open
Abstract
The exact clinical course and factors associated with persistent endocrine immune-related adverse events (irAEs) are not well-established. Elucidation of these information will aid irAEs screening and follow-up planning for patients on immunotherapy. We analysed the clinical course of endocrine irAEs including thyroid and pituitary dysfunction and insulin-dependent diabetes mellitus (IDDM), identified factors associated with persistent thyroid dysfunction, and determined the association between endocrine irAEs and survival parameters. This retrospective observational study enrolled patients with metastatic cancer who underwent anti-PD-1, anti-PD-L1, and/or anti-CTLA-4 treatment and developed endocrine irAE at the National University Cancer Institute, Singapore, between June 2015 and December 2020. Sixty-six patients with endocrine irAE were evaluated, with a median follow-up time of 15.7 months. The median time to onset of thyroid dysfunction, pituitary dysfunction, and IDDM was 1.8 months (range: 0.3–15.8 months), 6.8 months (range: 1.5–27.3 months), and 7.8 months (range: 1.4–9.1 months), respectively. Positive thyroperoxidase antibodies (TPOAb) and/ or thyroglobulin antibodies (TgAb) status at the time of thyroid dysfunction was associated with persistent thyroid dysfunction (OR 11.6, 95% CI 1.3–570.8, p = 0.02; OR 8.8, 95% CI 1.3–106.9, p = 0.01, respectively). All patients with pituitary irAE had central hypocortisolism. All patients with IDDM had grade 4 irAE. Patients with endocrine irAE had longer median survival times. Endocrine irAEs were associated with nonprogressive disease. The screening and follow-up approach for endocrine irAEs should be tailored according to each endocrinopathy’s clinical course. Early screening is imperative given its wide median time to onset.
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19
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Abstract
Pituitary autoimmunity is one of the principal causes of hypopituitarism. Additionally, hypophysitis is one of the immune-related adverse events associated with immunotherapy. Recent case-oriented research has revealed a novel type of autoimmune hypophysitis, anti-PIT-1 hypophysitis, related to isolated adrenocorticotropic hormone (ACTH) deficiency and immune checkpoint inhibitor-related hypophysitis, as a form of paraneoplastic syndrome. Under these conditions, the ectopic expression of pituitary antigens present in tumors evokes a breakdown of immune tolerance, resulting in the production of autoantibodies and autoreactive cytotoxic T cells that specifically harm pituitary cells. Consequently, an innovative clinical entity of paraneoplastic autoimmune hypophysitis has been purported. This novel concept and its underlying mechanisms provide clues for understanding the pathogenesis of autoimmune pituitary diseases and can be applied to other autoimmune diseases. This review discusses the etiology of paraneoplastic autoimmune hypophysitis and its future.
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Affiliation(s)
- Hironori Bando
- Division of Development of Advanced Therapy for Metabolic Diseases, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan; Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Keitaro Kanie
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yutaka Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan; Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan.
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20
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Yuen KCJ, Samson SL, Bancos I, Gosmanov AR, Jasim S, Fecher LA, Weber JS. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGY (AACE) DISEASE STATE CLINICAL REVIEW EVALUATION AND MANAGEMENT OF IMMUNE CHECKPOINT INHIBITOR-MEDIATED ENDOCRINOPATHIES: A PRACTICAL CASE-BASED CLINICAL APPROACH. Endocr Pract 2022; 28:719-731. [PMID: 35477029 DOI: 10.1016/j.eprac.2022.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this case-based clinical review is to provide a practical approach for clinicians regarding the management of patients with immune checkpoint inhibitor (ICI)-mediated endocrinopathies. METHODS A literature search was conducted using PubMed, Embase and Scopus, and appropriate keywords. The discussions and strategies for diagnosis and management of ICI-mediated endocrinopathies are based on evidence available from prospective randomized clinical studies, cohort studies, cross-sectional studies, case-based studies, and expert consensus. RESULTS Immunotherapy with ICIs has transformed the treatment landscape of diverse cancer types, but frequently results in immune-mediated endocrinopathies that can cause acute and persistent morbidity, and rarely, death. The patterns of endocrinopathies differ between inhibitors of the CTLA-4 and PD-1/PD-L1 pathways, but most often involve the thyroid and pituitary glands. Less common but important presentations include insulin-deficient diabetes mellitus, primary adrenal insufficiency, primary hypoparathyroidism, central diabetes insipidus, primary hypogonadism, and pancreatitis with or without subsequent progression to diabetes or exocrine insufficiency. CONCLUSION In recent years, with increasing numbers of cancer patients being treated with ICIs, more clinicians in a variety of specialties are called upon to diagnose and treat ICI-mediated endocrinopathies. Herein, we review case scenarios of various clinical manifestations, and emphasize the need for a high index of clinical suspicion by all clinicians caring for these patients including endocrinologists, oncologists, primary care providers, and emergency department physicians. We also provide diagnostic and therapeutic approaches for ICI-induced endocrinopathies, and we propose that patients on ICI-therapy be evaluated and treated in a multidisciplinary team in collaboration with endocrinologists.
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Affiliation(s)
- Kevin C J Yuen
- Co-Chair of Task Force; Professor of Medicine, Department of Medicine, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona.
| | - Susan L Samson
- Co-Chair of Task Force; Senior Associate Consultant, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Jacksonville, Florida
| | - Irina Bancos
- Associate Professor of Medicine; Associate Program Director, Endocrinology Fellowship Program, Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, MN
| | - Aidar R Gosmanov
- Professor of Medicine, Division of Endocrinology, Albany Medical College; Chief, Endocrinology Section, Stratton VAMC, Albany, NY
| | - Sina Jasim
- Associate Professor of Medicine, Washington University in St. Louis, School of Medicine, Division of Endocrinology, Metabolism and Lipid Research, St. Louis, Missouri
| | - Leslie A Fecher
- ASCO Representative, Associate Professor of Medicine and Dermatology, University of Michigan, Rogel Cancer Center, Ann Arbor, Michigan
| | - Jeffrey S Weber
- ASCO Representative, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York
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21
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Barnabei A, Strigari L, Corsello A, Paragliola RM, Falzone L, Salvatori R, Corsello SM, Torino F. Immune Checkpoint Inhibitor-Induced Central Diabetes Insipidus: Looking for the Needle in the Haystack or a Very Rare Side-Effect to Promptly Diagnose? Front Oncol 2022; 12:798517. [PMID: 35311088 PMCID: PMC8927719 DOI: 10.3389/fonc.2022.798517] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/09/2022] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitors have improved the survival in patients affected by an increasing number of malignancies, but they may also trigger various autoimmune side-effects, including endocrinopathies. Very rarely, immune checkpoint inhibitors have been reported to cause central diabetes insipidus. However, with their expanding use, the likelihood that oncologists will face this endocrine adverse event is expected to increase. By reviewing the limited literature on central diabetes insipidus induced by immune checkpoint inhibitors, some inconsistencies emerge in the diagnosis and the management of patients presenting with this toxicity, together with difficulties related to classifying its severity. Until now, specific guidelines on the management of central diabetes insipidus induced by immune checkpoint inhibitors are lacking. In clinical practice, endocrinological consultation may relieve medical oncologists from difficulties in treating this side-effect; oncologists, however, remain responsible for its early diagnose and the management of the causative drugs. To this aim, some practical suggestions are advised for the multidisciplinary management of cancer patients presenting with central diabetes insipidus induced by immune checkpoint inhibitors.
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Affiliation(s)
- Agnese Barnabei
- Endocrinology Unit, Presidio Ospedaliero Santo (P. O. S.) Spirito in Sassia, Azienda Sanitaria Locale (ASL) Roma 1, Rome, Italy
| | - Lidia Strigari
- Medical Physics Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Corsello
- Department of Translational Medicine and Surgery, Unit of Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico "Gemelli" Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Rosa Maria Paragliola
- Department of Translational Medicine and Surgery, Unit of Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico "Gemelli" Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Luca Falzone
- Epidemiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale Tumori "Fondazione G. Pascale", Naples, Italy
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism and Pituitary Center, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Salvatore Maria Corsello
- Department of Translational Medicine and Surgery, Unit of Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico "Gemelli" Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,UniCamillus Chair of Endocrinology, Saint Camillus International University of Health Sciences, Rome, Italy
| | - Francesco Torino
- Department of Systems Medicine, Medical Oncology, Tor Vergata University of Rome, Rome, Italy
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22
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Hypersensitivity Reactions and Immune-Related Adverse Events to Immune Checkpoint Inhibitors: Approaches, Mechanisms, and Models. Immunol Allergy Clin North Am 2022; 42:285-305. [DOI: 10.1016/j.iac.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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Barnabei A, Corsello A, Paragliola RM, Iannantuono GM, Falzone L, Corsello SM, Torino F. Immune Checkpoint Inhibitors as a Threat to the Hypothalamus-Pituitary Axis: A Completed Puzzle. Cancers (Basel) 2022; 14:cancers14041057. [PMID: 35205804 PMCID: PMC8870574 DOI: 10.3390/cancers14041057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICI) prolong the survival in an increasing number of patients affected by several malignancies, but at the cost of new toxicities related to their mechanisms of action, autoimmunity. Endocrine toxicity frequently occurs in patients on ICI, but endocrine dysfunctions differ based on the ICI-subclass, as follows: agents targeting the CTLA4-receptor often induce hypophysitis and rarely thyroid dysfunction, which is the opposite for agents targeting the PD-1/PD-L1 axis. Recently, few cases of central diabetes insipidus have been reported as an adverse event induced by both ICI-subclasses, either in the context of anterior hypophysitis or as selective damage to the posterior pituitary or in the context of hypothalamitis. These new occurrences demonstrate, for the first time, that ICI-induced autoimmunity may involve any tract of the hypothalamic-pituitary axis. However, the related pathogenic mechanisms remain to be fully elucidated. Similarly, the data explaining the endocrine system susceptibility to primary and ICI-induced autoimmunity are still scarce. Since ICI clinical indications are expected to expand in the near future, ICI-induced autoimmunity to the hypothalamic-pituitary axis presents as a unique in vivo model that could help to clarify the pathogenic mechanisms underlying both the dysfunction induced by ICI to the hypothalamus-pituitary axis and primary autoimmune diseases affecting the same axis.
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Affiliation(s)
- Agnese Barnabei
- Endocrinology Unit, P.O.—S. Spirito in Sassia, ASL Roma 1, Lungotevere in Sassia 1, I-00193 Rome, Italy;
| | - Andrea Corsello
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Largo Gemelli 8, I-00168 Rome, Italy; (A.C.); (R.M.P.); (S.M.C.)
| | - Rosa Maria Paragliola
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Largo Gemelli 8, I-00168 Rome, Italy; (A.C.); (R.M.P.); (S.M.C.)
| | - Giovanni Maria Iannantuono
- Medical Oncology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, I-00133 Rome, Italy;
| | - Luca Falzone
- Epidemiology Unit, IRCCS Istituto Nazionale Tumori ‘Fondazione G. Pascale’, I-80131 Naples, Italy;
| | - Salvatore Maria Corsello
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Largo Gemelli 8, I-00168 Rome, Italy; (A.C.); (R.M.P.); (S.M.C.)
- UniCamillus, Saint Camillus International University of Health Sciences, Via di Sant’Alessandro, 8, I-00131 Rome, Italy
| | - Francesco Torino
- Medical Oncology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, I-00133 Rome, Italy;
- Correspondence: ; Tel.: +39-062-090-8190
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Chera A, Stancu AL, Bucur O. Thyroid-related adverse events induced by immune checkpoint inhibitors. Front Endocrinol (Lausanne) 2022; 13:1010279. [PMID: 36204105 PMCID: PMC9530140 DOI: 10.3389/fendo.2022.1010279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/29/2022] [Indexed: 11/24/2022] Open
Abstract
Immune checkpoint inhibitors, namely anti-CTLA-4, anti-PD-1 and anti-PD-L1 monoclonal antibodies, have emerged in the last decade as a novel form of cancer treatment, promoting increased survival in patients. As they tamper with the immune response in order to destroy malignant cells, a new type of adverse reactions has emerged, known as immune-related adverse events (irAEs), which frequently target the endocrine system, especially the thyroid and hypophysis. Thyroid irAEs include hyperthyroidism, thyrotoxicosis, hypothyroidism and a possibly life-threatening condition known as the "thyroid storm". Early prediction of occurrence and detection of the thyroid irAEs should be a priority for the clinician, in order to avoid critical situations. Moreover, they are recently considered both a prognostic marker and a means of overseeing treatment response, since they indicate an efficient activation of the immune system. Therefore, a multidisciplinary approach including both oncologists and endocrinologists is recommended when immune checkpoint inhibitors are used in the clinic.
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Affiliation(s)
- Alexandra Chera
- Victor Babes National Institute of Pathology, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Andreea Lucia Stancu
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Octavian Bucur
- Victor Babes National Institute of Pathology, Bucharest, Romania
- Viron Molecular Medicine Institute, Boston, MA, United States
- *Correspondence: Octavian Bucur, ;;
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25
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The Price of Success: Immune-Related Adverse Events from Immunotherapy in Lung Cancer. Curr Oncol 2021; 28:4392-4407. [PMID: 34898551 PMCID: PMC8628657 DOI: 10.3390/curroncol28060373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/19/2021] [Accepted: 10/31/2021] [Indexed: 12/19/2022] Open
Abstract
Cancer immunotherapy has the goal of enhancing a patient’s intrinsic immune processes in order to mount a successful immune response against tumor cells. Cancer cells actively employ tactics to evade, delay, alter, or attenuate the anti-tumor immune response. Immune checkpoint inhibitors (ICIs) modulate endogenous regulatory immune mechanisms to enhance immune system activation, and have become the mainstay of therapy in many cancer types. This activation occurs broadly and as a result, activation is supraphysiologic and relatively non-specific, which can lead to immune-related adverse events (irAEs), the frequency of which depends on the patient, the cancer type, and the specific ICI antibody. Careful assessment of patients for irAEs through history taking, physical exam, and routine laboratory assessments are key to identifying irAEs at early stages, when they can potentially be managed more easily and before progressing to higher grades or more serious effects. Generally, most patients with low grade irAEs are eligible for re-challenge with ICIs, and the use of corticosteroids to address an irAE is not associated with poorer patient outcomes. This paper reviews immune checkpoint inhibitors (ICIs) including their mechanisms of action, usage, associated irAEs, and their management.
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Percik R, Liel Y, Urban D, Bar J, Ben-Ami E, Abu Tailakh M. Thyroid dysfunction and survival in cancer patients treated with immune checkpoint inhibitors: analyses from a large single tertiary cancer center database. Acta Oncol 2021; 60:1466-1471. [PMID: 34379562 DOI: 10.1080/0284186x.2021.1958006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE We aimed to assess the incidence, clinical and biochemical course of immunotherapy-induced thyroiditis and its implication on patients' survival, based on an extensive clinical experience from a tertiary cancer center. METHODS Analyses were based on data from the electronic medical records of cancer patients treated with CPIs. Data included demographic characteristics, cancer type, Thyroid function tests (TFT), and survival. RESULTS Thyroid function tests were available for 934 patients. After excluding patients with impaired baseline TFT or levothyroxine treatment, 754 euthyroid patients were included in the core analyses. Of those, 301 (39.9%) patients developed thyroid dysfunction ('thyroiditis'). Thyroiditis was more prevalent in patients with renal cell carcinoma than other types of cancer. Survival rates were comparable in patients who developed thyroiditis and in those who did not. during the 5 years follow-up period, there was a non-significant trend toward improved survival in patients who developed TD in four predefined groups: melanoma, lung cancer, renal cell carcinoma, and transitional cell carcinoma. Nevertheless, we observed a highly significant survival benefit for patients with renal cell carcinoma who developed TD (HR = 0.19, 95% CI 0.06-0.60; p = 0.005). CONCLUSIONS Thyroiditis is common, often asymptomatic, and is more prevalent in patients treated with combinations of nivolumab and PD-L1 inhibitors, and in patients with renal cell carcinoma. Thyroiditis was associated with a trend for a survival benefit, particularly in patients with renal cell carcinoma.
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Affiliation(s)
- Ruth Percik
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Institute of Oncology, Endo-Oncology Clinic, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Liel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Damien Urban
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Jair Bar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Eytan Ben-Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Muhammad Abu Tailakh
- Department of Nursing, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Soroka University Medical Center, Beer-Sheva, Israel
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27
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He J, Xu J, Gao J, Qian L. Myalgias upon PD-1 checkpoint blockade: Think of immunotherapy induced hypothyroid myopathy. Eur J Cancer 2021; 155:38-41. [PMID: 34352569 DOI: 10.1016/j.ejca.2021.06.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/13/2021] [Accepted: 06/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Jian He
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province 230031, China
| | - Jiang Xu
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Jin Gao
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province 230031, China.
| | - Liting Qian
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province 230031, China.
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28
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Kotwal A. Hypophysitis from immune checkpoint inhibitors: challenges in diagnosis and management. Curr Opin Endocrinol Diabetes Obes 2021; 28:427-434. [PMID: 34183541 DOI: 10.1097/med.0000000000000652] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This review will summarize the most recent and pertinent evidence regarding immune checkpoint inhibitor (ICI)-induced hypophysitis to describe diagnostic and management algorithm with the help of a case report. RECENT FINDINGS Hypophysitis is the most common endocrine adverse event from CTLA-4 inhibitors and much less with PD-1/PD-L1 inhibitors. Its pathophysiology appears to be lymphocytic, predominantly affecting the anterior pituitary. The utility of high-dose glucocorticoids for treatment has been questioned, as they do not influence recovery of hypopituitarism and may reduce survival. A survival benefit with hypophysitis has been suggested. SUMMARY The nonspecific nature of symptoms underlies the importance of clinical and hormonal monitoring especially in the first 6 months of CTLA-4 inhibitor cancer therapy. Adrenal insufficiency can be a diagnostic and management challenge, which persists in most cases; hence, a multidisciplinary team of oncologists and endocrinologists is essential for providing high-quality care to these patients. High-dose glucocorticoids should be reserved for mass effect or optic chiasm impingement. The ICI may need to be temporarily withheld but not discontinued. A survival advantage in cancer patients that develop ICI-induced hypophysitis may be a silver lining, especially as ICIs are being investigated for advanced endocrine malignancies.
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Affiliation(s)
- Anupam Kotwal
- Division of Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, Omaha, Nebraska, USA
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29
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Yuen KCJ, Mortensen MJ, Azadi A, Fonkem E, Findling JW. Rethinking the management of immune checkpoint inhibitor-related adrenal insufficiency in cancer patients during the COVID-19 pandemic. Endocrinol Diabetes Metab 2021; 4:e00246. [PMID: 34268454 PMCID: PMC8250331 DOI: 10.1002/edm2.246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction The coronavirus disease 2019 (COVID-19) is currently a major pandemic challenge, and cancer patients are at a heightened risk of severity and mortality from this infection. In recent years, immune checkpoint inhibitor (ICI) use to treat multiple cancers has increased in oncology, but equally has raised the question of whether ICI therapy and its side-effects is harmful or beneficial during this pandemic. Methods A combination of published literature in PubMed between January 2010 and December 2020, recommended guidelines in non-cancer patients, and clinical experience was utilized to outline recommendations on glucocorticoid timing and dosing regimens in ICI-treated patients presenting with AI during this COVID-19 pandemic. Results The potential immune interaction between ICIs and COVID-19 require major consideration because these agents act at the intersection between effective cancer immunotherapy and increasing patient susceptibility, severity and complications from the SARS-CoV-2 sepsis. Furthermore, ICI use can induce autoimmune adrenal insufficiency (AI) that further increases infection susceptibility. Thus, ICI-treated cancer patients with AI may be at greater risk of COVID-19 infection. Glucocorticoids are the cornerstone for replacement therapy, and for treatment and mitigation of adrenal crisis and relief of mass effects in ICI-related hypophysitis. High-dose glucocorticoids have also been used with cytotoxic chemotherapy as part of cancer treatment, and iatrogenic AI may arise after glucocorticoid discontinuation that increases the risk of adrenal crisis. Furthermore, in patients who develop the "long COVID-19" syndrome, when to discontinue glucocorticoid therapy becomes crucial to avoid unnecessary prolongation of therapy and the development of iatrogenic hypercortisolemia. Conclusion During the COVID-19 pandemic, much of cancer care have been impacted and an important clinical question is how to optimally manage ICI-related AI during these unprecedented times. Herein, we suggest practical recommendations on the timing and dosing regimens of glucocorticoids in different clinical scenarios of ICI-treated cancer patients presenting with AI during this COVID-19 pandemic.
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Affiliation(s)
- Kevin C. J. Yuen
- Departments of Neuroendocrinology and NeurosurgeryBarrow Neurological InstituteUniversity of Arizona College of Medicine and Creighton School of MedicinePhoenixArizonaUSA
| | | | - Amir Azadi
- Departments of Neurology and Neuro‐OncologyBarrow Neurological Institute/Ivy Brain Center at PhoenixSt. Joseph’s Hospital and Medical CenterPhoenixArizonaUSA
| | - Ekokobe Fonkem
- Departments of Neurology and Neuro‐OncologyBarrow Neurological Institute/Ivy Brain Center at PhoenixSt. Joseph’s Hospital and Medical CenterPhoenixArizonaUSA
| | - James W. Findling
- Division of Endocrinology and Molecular MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
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30
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Mai K, Fassnacht M, Führer-Sakel D, B. Honegger J, M. Weber M, Kroiss M. The Diagnosis and Management of Endocrine Side Effects of Immune Checkpoint Inhibitors. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0143. [PMID: 33724917 PMCID: PMC8378258 DOI: 10.3238/arztebl.m2021.0143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/01/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The immunologically mediated side effects of immune checkpoint inhibitors (CPI) often involve the endocrine system as well, and they can even be fatal, as in the case of unrecognized hypophysitis. Distinguishing such side effects from tumor-related changes is often difficult, because their clinical features can be nonspecific. METHODS This review is based on publications retrieved by a selective search in PubMed, with special attention to international recommendations. RESULTS Depending on their target molecules, the CPI now in use differ from one another in the incidence of side effects such as autoimmune thyroid disease (4-16%), hypophysitis (0.1- 18%), adrenalitis (0.7-8%), and autoimmune diabetes mellitus (0.5-2%). The typical clinical warning signs and laboratory constellations of hypophysitis include exhaustion, hyponatremia, and headache. Hypo- and hyperthyroidism and primary adrenocortical insufficiency likewise have nonspecific manifestations. Autoimmune diabetes mellitus often takes a fulminant course. Patients being treated with CPI should be monitored at close intervals, at least as frequently as the administration of the drug, so that endocrine side effects can be recognized in time. In case of doubt, glucocorticoid supplementation should be given whenever hypocortisolism is suspected, even before endocrine evaluation is completed and the results are available. Interrupting or discontinuing CPI treatment is rarely indicated. CONCLUSION With the increasing number of patients being treated with CPI, more and more physicians from a wide variety of specialties, not necessarily working in specialized centers, now have to consider immunologically mediated endocrine side effects in the differential diagnosis, and treat them properly when they arise. These things should be done in collaboration with endocrinologists. The ongoing study of such side effects of the CPI now in use, and of those that will be introduced in the future, is important and will lead to improved understanding.
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Affiliation(s)
- Knut Mai
- Department of Endocrinology, Diabetes and Nutrition, Charité–Universitätsmedizin Berlin: Prof. Dr. med. Knut Mai
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University of Würzburg, University Hospital Würzburg, Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
| | - Dagmar Führer-Sakel
- Department of Endocrinology, Diabetology and Metabolism, Essen University Hospital, University of Duisburg-Essen: Prof. Dr. med. Dr. rer. nat. Dagmar Führer-Sakel
| | - Jürgen B. Honegger
- Department of Neurosurgery, Tübingen University Hospital: Prof. Dr. med. Jürgen B. Honegger
| | - Matthias M. Weber
- Department of Internal Medicine I, Endocrinology, Johannes Gutenberg University Hospital Mainz: Prof. Dr. med. Matthias M. Weber
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University of Würzburg, University Hospital Würzburg, Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Department of Internal Medicine IV, Ludwig-Maximilians-University Munich: Prof. Dr. med.Dr. rer. nat. Matthias Kroiss
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Kang MJ. Management of adverse events in cancer treatment with immune checkpoint inhibitors. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.5.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The use of immune checkpoint inhibitors is associated with a spectrum of immune-related adverse events related to the mechanism of action which is quite different from that of cytotoxic chemotherapy. Adverse effects can affect multiple organs of the body and are most common in the skin, gastrointestinal tract, lungs, and endocrine tissues, including the thyroid, adrenal gland, pituitary gland, as well as musculoskeletal, renal, nervous, hematologic, cardiovascular, and ocular systems. Any changes should be considered as being related to treatment with immune checkpoint inhibitors. Adverse events are very infrequent, but may be very serious and, even lethal, such as neurological disorders and myocarditis. When compared with standard chemotherapeutic agents, programmed death 1/programmed deathligand 1inhibitors are associated with a lower incidence of bone marrow suppression, anorexia, nausea, vomiting, and diarrhea. Immune checkpoint inhibitor therapy can usually continue in the presence of mild immune-related adverse events with close monitoring. However, moderate to severe immune-related adverse events may be associated with a severe decline in organ function and quality of life, and may result in fatal outcomes. Hence, these toxicities require early detection and proper management. The management of immune-related adverse events usually involves corticosteroid therapy or the use of immunomodulators. The use of immune checkpoint inhibitors in patients with preexisting autoimmune disease or a history of prior organ transplant should include careful consideration and a robust discussion of potential risks and benefits.
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Coniac S, Stoian M. UPDATES IN ENDOCRINE IMMUNE-RELATED ADVERSE EVENTS IN ONCOLOGY IMMUNOTHERAPY. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2021; 17:286-289. [PMID: 34925584 PMCID: PMC8665257 DOI: 10.4183/aeb.2021.286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Immunotherapy in Oncology, a fundamental distinctive treatment in cancer patients, needs molecules with different mechanisms: immune checkpoint inhibitors (ICIs) who attenuate the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and the programmed cell death 1 (PD-1)/ligand 1 (PD-L1) pathways, depriving cancer cells of a key strategy of evasion from immunosurveillance. Although their success in improving overall patient survival, unfortunately, superior clinical response of immunotherapy is often associated with treatment toxicity. European Society of Medical Oncology (ESMO) published in 2021 a comprehensive review of qualitatively resynthesized information on endocrinopathies after cancer immunotherapy with ICIs with practical recommendations for screening and management. Endocrinopathy such as thyroid dysfunctions, hypophysitis, primary adrenal insufficiency, type 1 diabetes mellitus, central diabetes insipidus, or hypoparathyroidism were reported and called immune-related adverse effects (irAEs). Practical guidelines for monitoring, diagnosis, and treatment of ICIs related endocrine toxicities are constantly updated. Given the increasing use of ICIs, cooperation between oncologists and endocrinologists is crucial in the management of oncologic patients.
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Affiliation(s)
- S. Coniac
- “Carol Davila” University of Medicine and Pharmacy, Faculty of General Medicine, Bucharest, Romania
- Coltea Hospital, Oncology Clinic, Bucharest, Romania
| | - M. Stoian
- “Dr Ion Cantacuzino” Hospital, Bucharest, Romania
- Coltea Hospital, Oncology Clinic, Bucharest, Romania
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Yoon JH, Hong AR, Kim HK, Kang HC. Characteristics of Immune-Related Thyroid Adverse Events in Patients Treated with PD-1/PD-L1 Inhibitors. Endocrinol Metab (Seoul) 2021; 36:413-423. [PMID: 33820396 PMCID: PMC8090457 DOI: 10.3803/enm.2020.906] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/17/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thyroid immune-related adverse events (IRAEs) have been reported in patients treated with programmed cell death protein-1 (PD-1) and programmed cell death protein-ligand 1 (PD-L1) inhibitors. We investigated the incidence and clinical course of PD-1/PD-L1 inhibitor-induced thyroid IRAEs, and identified predictable clinical risk factors of thyroid IRAEs, in particular, overt hypothyroidism (OH). METHODS We retrospectively reviewed the medical records of 325 cancer patients receiving PD-1/PD-L1 inhibitor in a tertiary referral center. RESULTS A total of 50.5% (164/325) of patients experienced at least one abnormal thyroid function following PD-1/PD-L1 inhibitor. Eighty-four patients (51.2%) of them recovered to normal thyroid function during follow-up. In overall population, 25 patients (7.7%) required thyroid hormone replacement therapy due to PD-1/PD-L1 inhibitor-induced OH. Patients who progressed to OH showed significantly higher baseline thyroid stimulating hormone level and longer duration of PD-1/PD-L1 inhibitor therapy than those without thyroid dysfunction or OH (both P<0.001). Median time interval to the development of OH was 3 months after the therapy. OH was significantly associated with positive anti-thyroid peroxidase antibody at baseline and anti-thyroglobulin antibody during the therapy than those without thyroid dysfunction or OH (P=0.015 and P=0.005, respectively). We observed no patients with OH who were able to stop levothyroxine replacement after the cessation of PD-1/PD-L1 inhibitor therapy. CONCLUSION PD-1/PD-L1 inhibitor-induced thyroid dysfunctions are considerably reversible; however, OH is irreversible requiring levothyroxine replacement even after stopping the therapy. Positive thyroid autoantibodies may predict the progression to OH.
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Affiliation(s)
- Jee Hee Yoon
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - A Ram Hong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hee Kyung Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ho-Cheol Kang
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Goyal I, Pandey MR, Sharma R, Chaudhuri A, Dandona P. The side effects of immune checkpoint inhibitor therapy on the endocrine system. Indian J Med Res 2021; 154:559-570. [PMID: 35435341 PMCID: PMC9205006 DOI: 10.4103/ijmr.ijmr_313_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a relatively newer class of drugs approved for the treatment of malignancies such as melanoma, renal, bladder and lung cancer. Immune-related adverse events (IrAEs) involving the endocrine system are a common side effect of these drugs. The spectrum of endocrine adverse events varies by the drug class. Cytotoxic T-lymphocyte–associated antigen-4 inhibitors commonly cause hypophysitis/hypopituitarism, whereas the incidence of thyroid disease is higher with programmed cell death (PD)-1/ ligand (PD-L) protein 1 inhibitors. The focus of this review is to describe the individual endocrinopathies with their possible mechanisms, signs and symptoms, clinical assessment and disease management. Multiple mechanisms of IrAEs have been described in literature including type II/IV hypersensitivity reactions and development of autoantibodies. Patients with pre-existing autoimmune endocrine diseases can have disease exacerbation following ICI therapy rather than de novo IrAEs. Most of the endocrinopathies are relatively mild, and timely hormone replacement therapy allows continuation of ICIs. However, involvement of the pituitary–adrenal axis could be life-threatening if not recognized. Corticosteroids are helpful when the pituitary–adrenal axis is involved. In cases of severe endocrine toxicity (grade 3/4), ICIs should be temporarily discontinued and can be restarted after adequate hormonal therapy. Endocrinologists and general internists need to be vigilant and maintain a high degree of awareness for these adverse events.
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Affiliation(s)
- Itivrita Goyal
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
| | - Manu Raj Pandey
- Department of Hematology & Oncology, State University of New York at Buffalo; Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Rajeev Sharma
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo; Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Ajay Chaudhuri
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
| | - Paresh Dandona
- Department of Endocrinology, Diabetes & Metabolism, State University of New York at Buffalo, Buffalo, NY, USA
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Yatsuda Y, Hirose S, Ito Y, Onoda T, Sugiyama Y, Nagafuchi M, Suzuki H, Niisato Y, Tange Y, Ikeda T, Yamada T, Yamamoto Y, Ohyama Osawa M, Sakamoto N, Moriwaki T, Mizokami Y. A Durable Response after the Discontinuation of Nivolumab in an Advanced Gastric Cancer Patient. Intern Med 2021; 60:1011-1017. [PMID: 33162479 PMCID: PMC8079905 DOI: 10.2169/internalmedicine.5893-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A durable response after the discontinuation of immune checkpoint-inhibitor therapy has previously been reported in several cancers. We herein describe a patient with gastric cancer who maintained a durable response after the discontinuation of nivolumab. A 65-year-old man was treated with nivolumab as a sixth-line therapy for recurrent gastric cancer. After four cycles of nivolumab therapy, he showed a partial response. But the treatment was discontinued when two immune-related adverse events occurred after six cycles. Disease regression was sustained for approximately 2 years, without the re-administration of nivolumab. The characteristics leading to such responses are unclear, and further studies are warranted in this regard.
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Affiliation(s)
- Yukino Yatsuda
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Suguru Hirose
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Yoshimi Ito
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Tsubasa Onoda
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Yutaro Sugiyama
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Miho Nagafuchi
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Hirosumi Suzuki
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Yusuke Niisato
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Yoshitaka Tange
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Takafumi Ikeda
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Takeshi Yamada
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Yoshiyuki Yamamoto
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Mariko Ohyama Osawa
- Department of Internal Medicine (Endocrinology and Metabolism), Faculty of Medicine, University of Tsukuba, Japan
| | - Noriaki Sakamoto
- Department of Diagnostic Pathology, Faculty of Medicine, University of Tsukuba, Japan
| | - Toshikazu Moriwaki
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
| | - Yuji Mizokami
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Japan
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Hattersley R, Nana M, Lansdown AJ. Endocrine complications of immunotherapies: a review. Clin Med (Lond) 2021; 21:e212-e222. [PMID: 33762389 DOI: 10.7861/clinmed.2020-0827] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Use of immune checkpoint inhibitors in cancer treatment has increased vastly over the past decade, as both single and combination agent therapies. While having a positive impact on survival rates, adverse effects have been noted, with endocrine effects in around 10% of patients. Thyroid disease and hypophysitis are the most commonly encountered, with diabetes mellitus and primary adrenal insufficiency also reported, as well as more rare endocrinopathies. Patient and clinician education to raise awareness of these effects, as well as regular monitoring to enable early recognition, diagnosis and prompt treatment of the immune side effects, are key. In this review, we discuss the aetiology, presentation and management of the endocrine complications of immunotherapies that are relevant to the general physician, as well as highlighting important areas where further research is still needed.
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Hou W, Zhou X, Yi C, Zhu H. Immune Check Point Inhibitors and Immune-Related Adverse Events in Small Cell Lung Cancer. Front Oncol 2021; 11:604227. [PMID: 33816235 PMCID: PMC8016392 DOI: 10.3389/fonc.2021.604227] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/15/2021] [Indexed: 02/05/2023] Open
Abstract
Small cell lung cancer (SCLC) is a malignant solid tumor. In recent years, although immune check point inhibitors (ICIs) have achieved important advances in the treatment of SCLC, immune-related adverse events (irAEs) have occurred at the same time during the therapeutic period. Some irAEs lead to dose reduction or treatment rejection. The immune microenvironment of SCLC is complicated, therefore, understanding irAEs associated with ICIs is of great importance and necessity for the clinical management of SCLC. However, the lack of comprehensive understanding of irAEs in patients with SCLC remains remarkable. This review aims to provide an up-to-date overview of ICIs and their associated irAEs in patients with SCLC based on present clinical data.
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Affiliation(s)
- Wanting Hou
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaohan Zhou
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Yi
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Zhu
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Peravali M, Gomes-Lima C, Tefera E, Baker M, Sherchan M, Farid S, Burman K, Constantinescu F, Veytsman I. Racial disparities in immune-related adverse events of immune checkpoint inhibitors and association with survival based on clinical and biochemical responses. World J Clin Oncol 2021; 12:103-114. [PMID: 33680877 PMCID: PMC7918525 DOI: 10.5306/wjco.v12.i2.103] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/04/2021] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICPi) cause various immune-related adverse events (irAE) with thyroid dysfunction as a commonly reported abnormality. There is increasing evidence showing positive association with development of irAE and survival. However, prior trials with ICPi had underrepresentation of minorities with < 5% African Americans.
AIM To evaluate the association between development of irAE and survival outcomes among a racially diverse patient population.
METHODS Data on patients with stage IV solid malignancies treated with programmed cell death-protein 1/programmed death ligand 1 blockers between January 2013 and December 2018 across MedStar Georgetown Cancer Institute facilities were retrospectively reviewed. Patients treated with cytotoxic T-lymphocyte-associated protein 4 inhibitors were excluded. Progression free survival (PFS) and overall survival (OS) were primary endpoints and were calculated using Kaplan-Meier methods and Wilcoxon rank sum test for comparison.
RESULTS Out of 293 patients who met eligibility criteria, 91 pts (31%) had any grade irAE; most common AE were endocrine (40.7%) specifically TSH elevation, dermatological (23.1%) and rheumatologic (18.7%). Proportion of irAE was significantly higher in Caucasians vs African Americans (60.4% vs 30.8%), in patients with low programmed death ligand 1, lower LDH, older age, and those who had more treatment cycles with ICPi. Rate of progression was lower in patients with irAE (30.8% vs 46.0%, P = 0.0140). Median PFS (5.8 vs 3.0 mo, P = 0.0204) and OS (17.1 vs 7.2 mo, P < 0.0001) were higher with irAE. Statistically significant difference in OS (17.1 vs 8.6 mo, P = 0.0002) but not in PFS (5.8 vs 3.3 mo, P = 0.0545) was noted with endocrine irAE. No differences in survival were observed among other commonly reported irAE. Differences in survival among subgroups of patients with irAE are described.
CONCLUSION Development of irAE positively correlated with improved PFS and OS as reported in previous studies. To our knowledge, this is the first study observing differences in OS favoring endocrine AE and Caucasian race. These factors may be potential surrogate markers of prognosis pending replication of these results in large-scale studies.
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Affiliation(s)
- Monica Peravali
- Department of Hematology/Oncology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Cristiane Gomes-Lima
- Department of Endocrinology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Eshetu Tefera
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Washington, DC 20010, United States
| | - Mairead Baker
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Mamta Sherchan
- Department of Rheumatology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Saira Farid
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Kenneth Burman
- Department of Endocrinology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Florina Constantinescu
- Department of Rheumatology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Irina Veytsman
- Department of Hematology/Oncology, MedStar Washington Hospital Center, Washington, DC 20010, United States
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Immune Checkpoint Inhibitor-Induced Diabetes Mellitus: Potential Role of T Cells in the Underlying Mechanism. Int J Mol Sci 2021; 22:ijms22042093. [PMID: 33672515 PMCID: PMC7923776 DOI: 10.3390/ijms22042093] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 12/18/2022] Open
Abstract
Immunotherapy is now a recognized treatment option for several types of cancer. However, some cancer patients treated with immune checkpoint inhibitors (ICIs) are subject to immune-related adverse events, including induced diabetes mellitus. The exact role and molecular/genetic action of ICIs in diabetes are still not well understood. Elucidating the underlying mechanisms in a proper fashion would allow better refining of biomarkers that would help diagnose patients at risk of altered immune system homeostasis, but would also hold the potential of new therapeutic options for diabetes. In the present narrative review, we propose to discuss the case of autoimmune diabetes following treatment with ICIs and the role of ICIs in the pathophysiology of diabetes. We also present some scarce available data on interesting potential immune therapies for diabetes.
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40
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Endokrinologische Notfälle. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00766-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Barnabei A, Carpano S, Chiefari A, Bianchini M, Lauretta R, Mormando M, Puliani G, Paoletti G, Appetecchia M, Torino F. Case Report: Ipilimumab-Induced Panhypophysitis: An Infrequent Occurrence and Literature Review. Front Oncol 2020; 10:582394. [PMID: 33335854 PMCID: PMC7736611 DOI: 10.3389/fonc.2020.582394] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/28/2020] [Indexed: 12/19/2022] Open
Abstract
Background Immune checkpoint inhibitors (ICIs), by unleashing the anticancer response of the immune system, can improve survival of patients affected by several malignancies, but may trigger a broad spectrum of adverse events, including autoimmune hypophysitis. ICI-related hypophysitis mainly manifests with anterior hypopituitarism, while the simultaneous involvement of both anterior and posterior pituitary (i.e., panhypophysitis) has rarely been described. Case Presentation In June 2015, a 64-year-old man affected by liver metastases of a uveal melanoma was referred to us due to polyuria and polydipsia. Two months prior, he had started ipilimumab therapy (3 mg/kg iv every 21 days). The treatment was well-tolerated (only mild asthenia and diarrhea were reported). A few days before the fourth cycle, the patient complained of intense headaches, profound fatigue, nocturia, polyuria (up to 10 L urine/daily), and polydipsia. Laboratory tests were consistent with adrenal insufficiency, hypothyroidism, and transient central diabetes insipidus. The pituitary MRI showed an enlarged gland with microinfarcts, while the hypophyseal stalk was normal, and the neurohypophyseal 'bright signal' in T1 sequences was not detected. The treatment included dexamethasone (then cortisone acetate at replacement dose), desmopressin, and levothyroxine. Within the next five days, the symptoms resolved, and blood pressure, electrolytes, glucose, and urinalysis were stable within the normal ranges; desmopressin was discontinued while cortisone acetate and levothyroxine were maintained. The fourth ipilimumab dose was entirely administered in the absence of further side effects. Conclusion As ICIs are increasingly used as anticancer agents, the damage to anterior and/or posterior pituitary can be progressively encountered by oncologists and endocrinologists in their clinical practice. Patients on ICIs and their caregivers should be informed about that risk and be empowered to alert the referring specialists early, at the onset of panhypopituitarism symptoms, including polyuria/polydipsia.
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Affiliation(s)
- Agnese Barnabei
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Silvia Carpano
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alfonsina Chiefari
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Marta Bianchini
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Rosa Lauretta
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Marilda Mormando
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Guilia Puliani
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giancarlo Paoletti
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Marialuisa Appetecchia
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Francesco Torino
- Department of Systems Medicine, Medical Oncology, University of Rome Tor Vergata, Rome, Italy
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Gubbi S, Cordes LM, Klubo-Gwiezdzinska J, Madan RA, Nieman LK, Gulley JL, Del Rivero J. In Reply. Oncologist 2020; 26:e192-e193. [PMID: 33150998 DOI: 10.1002/onco.13589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/28/2020] [Indexed: 11/07/2022] Open
Affiliation(s)
- Sriram Gubbi
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa M Cordes
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Joanna Klubo-Gwiezdzinska
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Ravi A Madan
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lynnette K Nieman
- Diabetes, Endocrine, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - James L Gulley
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, National Cancer Institute, National Institute of Health, Bethesda, Maryland, USA
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Salinas C, Samtani S, Burotto M. Primary Adrenal Insufficiency due to Immune Checkpoint Inhibitors: More Common than We Thought. Oncologist 2020; 26:e191. [PMID: 33150991 DOI: 10.1002/onco.13588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/31/2020] [Indexed: 02/05/2023] Open
Abstract
Immunotherapy has changed the treatment landscape for cancer patients; however, immune-related adverse events, such as primary and secondary adrenal insufficiency, can be life threatening, with potential differences in population incidence. This letter to the editor reports a real-world experience of Hispanic/Latino patients treated with immunotherapy and the incidence of adrenal insufficiency.
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Affiliation(s)
- Carlos Salinas
- Centro de Investigación Clínica Bradford Hill, Santiago de Chile, Chile
| | - Suraj Samtani
- Centro de Investigación Clínica Bradford Hill, Santiago de Chile, Chile
| | - Mauricio Burotto
- Centro de Investigación Clínica Bradford Hill and Oncologia Medica, Clinica Universidad de los Andes, Santiago de Chile, Chile
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Abstract
PURPOSE To present a case series of primary and immunotherapy-related secondary hypophysitis. METHODS A single-center retrospective chart review was performed at the University of British Columbia, Vancouver, Canada. Eleven cases of primary hypophysitis and 2 cases of immunotherapy-related secondary hypophysitis were included. Of the 11 primary cases, 6 were diagnosed clinically without biopsy. RESULTS In primary hypophysitis, headache was the most common presenting symptom (6/11; 55%) and stalk enlargement the prevailing radiologic sign (8/11; 73%). Central adrenal insufficiency (4/11; 36%), central hypothyroidism (4/11; 36%), and central diabetes insipidus (CDI) (4/11; 36%) were the most common pituitary deficiencies at presentation. Initial management included surgery (4/11; 36%), supraphysiologic steroids (2/11; 18%), or observation (6/11; 55%). Outcomes assessed included radiologic improvement (8/9; 89%), improvement in mass symptoms (4/7; 57%), anterior pituitary recovery (1/7; 14%), and CDI recovery (0/4; 0%). In immunotherapy-related hypophysitis either under observation or supraphysiologic steroid therapy, the inflammatory mass resolved and pituitary dysfunction persisted. CONCLUSIONS In primary hypophysitis, the inflammatory pituitary mass typically resolves and hypopituitarism persists. In the absence of severe or progressive neurologic deficits, a presumptive clinical diagnosis and conservative medical management should be attempted. In the absence of severe features, immunotherapy-related hypophysitis may be managed effectively without the use of supraphysiologic steroids.
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Affiliation(s)
- Paul Atkins
- Department of Medicine, University of British Columbia , Vancouver, BC, Canada
| | - Ehud Ur
- Department of Medicine, University of British Columbia , Vancouver, BC, Canada
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Tsoli M, Kaltsas G, Angelousi A, Alexandraki K, Randeva H, Kassi E. Managing Ipilimumab-Induced Hypophysitis: Challenges and Current Therapeutic Strategies. Cancer Manag Res 2020; 12:9551-9561. [PMID: 33061641 PMCID: PMC7537807 DOI: 10.2147/cmar.s224791] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/19/2020] [Indexed: 12/12/2022] Open
Abstract
Over the past years, progress has been made in cancer immunotherapy following the development of immune checkpoint inhibitors (ICI) that have been proved effective in the management of many malignancies. Ipilimumab, a monoclonal antibody against cytotoxic T-lymphocyte antigen-4 (CTLA-4), has been approved for the treatment of advanced melanoma but has been associated with the development of several endocrine immune-related adverse events (irAEs). Hypophysitis is the most common endocrine irAE related to ipilimumab with a reported incidence ranging from 1.8% to 17%. The mechanism underlying ipilimumab-induced hypophysitis implicates immune, inflammatory and genetic factors, but there are still some points that are not well understood and remain to be elucidated. The diagnosis is based mainly on clinical, biochemical and imaging data. The majority of patients display multiple hormone deficiencies that may recover or persist for a prolonged period of time with corticotroph deficiency usually being permanent. Immune-related hypopituitarism is treated with replacement of deficient hormones while in severe forms of hypophysitis treatment with high-dose glucocorticoids may be required. Proper evaluation and registration of patients in clinical trials and further investigation are needed to precisely clarify the pathophysiology of the ICI-related hypophysitis, define predictive factors and ameliorate the management and outcome of the disease.
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Affiliation(s)
- Marina Tsoli
- First Department of Propaedeutic and Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory Kaltsas
- First Department of Propaedeutic and Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Angelousi
- First Department of Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Krystallenia Alexandraki
- First Department of Propaedeutic and Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Harpal Randeva
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Eva Kassi
- First Department of Propaedeutic and Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Kähler KC, Kosova K, Bohne AS, Schreiber S, Hauschild A. Increased risk of immune checkpoint inhibitor-induced type 1 diabetes mellitus with the new approved 6-week scheme of pembrolizumab in patients with melanoma? Eur J Cancer 2020; 138:169-171. [PMID: 32890812 DOI: 10.1016/j.ejca.2020.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/30/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Katharina C Kähler
- University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Department of Dermatology, Kiel, Germany.
| | - Katerina Kosova
- University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Department of Dermatology, Kiel, Germany
| | - Ann-Sophie Bohne
- University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Department of Dermatology, Kiel, Germany
| | - Sefan Schreiber
- University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Department of Dermatology, Kiel, Germany
| | - Axel Hauschild
- University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Department of Dermatology, Kiel, Germany
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Lopes AR, Russo A, Li AY, McCusker MG, Kroopnick JM, Scilla K, Mehra R, Rolfo C. Development of autoimmune diabetes with severe diabetic ketoacidosis and immune-related thyroiditis secondary to durvalumab: a case report. Transl Lung Cancer Res 2020; 9:2149-2156. [PMID: 33209634 PMCID: PMC7653143 DOI: 10.21037/tlcr-20-408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Immune-mediated endocrinopathies are among the most frequent immune-related adverse events (irAEs) with immune checkpoint inhibitors (ICIs) targeting programmed death-ligand 1 (PD-L1)/PD-1. However, the development of auto-immune diabetes is an uncommon event during PD(L)-1 blockade, either as monotherapy or in combination therapy. Here we report a case of a 75-year-old male with a mediastinal recurrence from a stage IA squamous cell carcinoma of the lung previously treated with stereotactic body radiotherapy (SBRT) who early developed a severe diabetic ketoacidosis (DKA) caused by new-onset auto-immune diabetes, with positive glutamic acid decarboxylase (GAD65) autoantibodies, during durvalumab consolidation therapy after concurrent chemoradiation. The patient had no personal or family history of diabetes or auto-immune diseases and was admitted after the second cycle of durvalumab to the intensive care unit (ICU) with severe DKA. During his hospitalization, insulin and fluid therapy were started and the patient had a favorable clinical course. Durvalumab treatment was interrupted and thyroiditis was verified during follow-up, without anti-thyroid antibodies, that progressed to subsequent hypothyroidism with need of thyroid hormone replacement therapy. This case highlights the rare irAE of autoimmune type 1 diabetes during anti-PD(L)-1 therapy, which can be life-threatening and requires adequate patient education and prompt medical treatment within a multidisciplinary team, including endocrinology and emergency medicine. Besides its low incidence, this case show how irAE must be taken in account about decision of ICI treatment, especially in curative setting, as they can be potentially fatal and impair overall survival. Furthermore, as reported in the present case, multiple endocrine irAEs can occur in the same patient either simultaneously or sequentially, suggesting that active surveillance is needed in those who develop endocrinopathies as a result of ICI treatment. Immune-mediated endocrinopathies are generally irreversible and cause life-long morbidity, which must be taken into consideration when deciding on further lines of treatment.
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Affiliation(s)
- Ana Rita Lopes
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Portuguese Institute of Oncology (IPO), Porto, Portugal
| | - Alessandro Russo
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Medical Oncology Unit, A.O. Papardo, Messina, Italy
| | - Andrew Y Li
- Department of Medicine, Division of General Internal Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Michael G McCusker
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey Myles Kroopnick
- University of Maryland Center for Diabetes and Endocrinology, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Katherine Scilla
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ranee Mehra
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christian Rolfo
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Wakabayashi G, Lee YC, Luh F, Kuo CN, Chang WC, Yen Y. Development and clinical applications of cancer immunotherapy against PD-1 signaling pathway. J Biomed Sci 2019; 26:96. [PMID: 31801525 PMCID: PMC6894306 DOI: 10.1186/s12929-019-0588-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 11/13/2019] [Indexed: 12/26/2022] Open
Abstract
Dramatic advances in immune therapy have emerged as a promising strategy in cancer therapeutics. In addition to chemotherapy and radiotherapy, inhibitors targeting immune-checkpoint molecules such as cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed cell death receptor-1 (PD-1) and its ligand (PD-L1) demonstrate impressive clinical benefits in clinical trials. In this review, we present background information about therapies involving PD-1/PD-L1 blockade and provide an overview of current clinical trials. Furthermore, we present recent advances involving predictive biomarkers associated with positive therapeutic outcomes in cancer immunotherapy.
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Affiliation(s)
| | - Yu-Ching Lee
- Center for Cancer Transnational Research, Taipei Medical University, 250 Wu-Hsing Street, Taipei, Taiwan, 110
| | - Frank Luh
- Sino-American Cancer Foundation, 668 Arrow Grand Circle, Suite 101, Covina, California, 91722, USA
| | - Chun-Nan Kuo
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University; Department of Pharmacy, Integrative Therapy Center for Gastroenterologic Cancers, Wan Fang Hospital; Taipei Medical University, 250 Wu-Hsing Street, Taipei, Taiwan, 110
| | - Wei-Chiao Chang
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University; Department of Pharmacy, Integrative Therapy Center for Gastroenterologic Cancers, Wan Fang Hospital; Taipei Medical University, 250 Wu-Hsing Street, Taipei, Taiwan, 110.
| | - Yun Yen
- PhD Program for Cancer Biology and Drug Discovery, Taipei Medical University, 250 Wu-Hsing Street, Taipei, Taiwan, 110.
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