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Teodorescu R, Liu H, Sadun AA. Pembrolizumab-Associated Optic Neuritis With an Unusual Manifestation of Monocular Optic Disc Edema. J Neuroophthalmol 2024; 44:e246-e248. [PMID: 36728538 DOI: 10.1097/wno.0000000000001798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Roxana Teodorescu
- Doheny Eye Institute (RT, HL, AAS), Los Angeles, California; and Department of Ophthalmology (AAS), David Geffen School of Medicine at University of California, Los Angeles, California
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2
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Shu X, Shao Y, Chen Y, Zeng C, Huang X, Wei R. Immune checkpoints: new insights into the pathogenesis of thyroid eye disease. Front Immunol 2024; 15:1392956. [PMID: 38817600 PMCID: PMC11137266 DOI: 10.3389/fimmu.2024.1392956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/01/2024] [Indexed: 06/01/2024] Open
Abstract
Thyroid eye disease (TED) is a disfiguring autoimmune disease characterized by changes in the orbital tissues and is caused by abnormal thyroid function or thyroid-related antibodies. It is the ocular manifestation of Graves' disease. The expression of thyroid-stimulating hormone receptor (TSHR) and the insulin-like growth factor-1 receptor (IGF-1 R) on the cell membrane of orbital fibroblasts (OFs) is responsible for TED pathology. Excessive inflammation is caused when these receptors in the orbit are stimulated by autoantibodies. CD34+ fibrocytes, found in the peripheral blood and orbital tissues of patients with TED, express immune checkpoints (ICs) like MHC II, B7, and PD-L1, indicating their potential role in presenting antigens and regulating the immune response in TED pathogenesis. Immune checkpoint inhibitors (ICIs) have significantly transformed cancer treatment. However, it can also lead to the occurrence of TED in some instances, suggesting the abnormality of ICs in TED. This review will examine the overall pathogenic mechanism linked to the immune cells of TED and then discuss the latest research findings on the immunomodulatory role of ICs in the development and pathogenesis of TED. This will offer fresh perspectives on the study of pathogenesis and the identification of potential therapeutic targets.
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Affiliation(s)
| | | | | | | | | | - Ruili Wei
- Department of Ophthalmology, Changzheng Hospital of Naval Medicine University, Shanghai, China
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3
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Chen A, Chwalisz BK. Update on Neuro-ophthalmic Manifestations of Immune Checkpoint Inhibitors. Curr Neurol Neurosci Rep 2024; 24:113-122. [PMID: 38498093 DOI: 10.1007/s11910-024-01336-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI) use has been on the rise for treatment of many different malignancies. Subsequently, more has been learned about immune-related adverse events (irAEs) that occur up to 12 months after treatment. This review summarizes the latest findings and management of neuro-ophthalmic associated irAEs. RECENT FINDINGS irAEs can affect the afferent and efferent neuro-ophthalmic pathways, thereby targeting central and peripheral nervous systems. As more cases are being reported, it is becoming apparent that neuro-ophthalmic irAEs often present with atypical features when compared to their spontaneous autoimmune counterparts. These neuro-ophthalmic presentations can also be signs of a more extensive inflammatory process that spans other organ systems, such as myopathies, endocrinopathies, and paraneoplastic syndromes. Awareness of neuro-ophthalmic irAEs and their atypical presentations can lead to early detection, termination of ICI treatment, and immunosuppressant therapy initiation.
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Affiliation(s)
- Amalie Chen
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Bart K Chwalisz
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, MA, USA.
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4
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Pedrero Prieto M, Gorriz Romero D, Gómez Roch E, Pérez Miralles FC, Casanova Estruch B. Neuromyelitis optica associated with the use of Atezolizumab in a patient with advanced lung adenocarcinoma. Neurol Sci 2024; 45:2199-2202. [PMID: 38091210 DOI: 10.1007/s10072-023-07252-3] [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: 08/07/2023] [Accepted: 12/04/2023] [Indexed: 04/17/2024]
Abstract
Immune checkpoint inhibitors (ICIs) are a pharmacological group increasingly used in Oncology and Hematology. These treatments can lead to autoimmune complications, with neurological conditions, especially central nervous system (CNS) involvement, being rare. We describe a case of seropositive neuromyelitis optica in a patient with locally advanced lung adenocarcinoma treated with Atezolizumab.
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Affiliation(s)
- Manuel Pedrero Prieto
- Neurology Department, University and Polytechnic Hospital La Fe, Fernando Abril Martorell Avenue 106, 46026, Valencia, Spain.
| | - David Gorriz Romero
- Neurology Department, University and Polytechnic Hospital La Fe, Fernando Abril Martorell Avenue 106, 46026, Valencia, Spain.
| | - Elisa Gómez Roch
- Oncology Department, University and Polytechnic Hospital La Fe, Fernando Abril Martorell Avenue 106, 46026, Valencia, Spain
| | - Francisco-Carlos Pérez Miralles
- Neurology Department, University and Polytechnic Hospital La Fe, Fernando Abril Martorell Avenue 106, 46026, Valencia, Spain
| | - Bonaventura Casanova Estruch
- Neurology Department, University and Polytechnic Hospital La Fe, Fernando Abril Martorell Avenue 106, 46026, Valencia, Spain
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5
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Park J, Hwang JM, Yang HK. Pembrolizumab-Associated Unilateral Optic Neuritis. J Clin Neurol 2024; 20:235-236. [PMID: 38212664 PMCID: PMC10921044 DOI: 10.3988/jcn.2023.0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/29/2023] [Accepted: 10/02/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Jihae Park
- Department of Ophthalmology, Daegu Fatima Hospital, Daegu, Korea
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee Kyung Yang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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6
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Ameri M, Al-Zubidi N, Lee AG. Immune checkpoint monoclonal antibody-related adverse effects in neuro-ophthalmology. Saudi J Ophthalmol 2024; 38:25-28. [PMID: 38628415 PMCID: PMC11017004 DOI: 10.4103/sjopt.sjopt_296_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 04/19/2024] Open
Abstract
Immunotherapy has renovated the field of oncology. Usually, cancer is treated by surgery, chemotherapy, and radiation. Immunotherapy is a promising treatment that harnesses the patient's own immune system to target cancer. Immune checkpoint inhibitors (ICIs) have proven to be a promising treatment avenue for managing cancer; however, their use had been associated with a unique spectrum of adverse side effects called immune-related adverse events (irAEs). As ICIs become increasingly relevant in cancer management, it is crucial to address these irAEs affecting various systems in the body, including the skin, liver, gastrointestinal tract, endocrine system, and the eye. Ocular toxicity and sight-threatening events are among the reported irAEs, impacting diverse ocular tissues. The most commonly reported ocular irAEs (OirAEs) are blurred vision, conjunctivitis, ocular surface disease uveitis, scleritis, and retinopathy. Nevertheless, the frequency and severity of these OirAEs can vary, even within the same class of ICIs. Thus, OirAEs can significantly impact the quality of life and patient compliance. Therefore, we aim to comprehensively analyze uncommon and severe ICI-related OirAEs associated with lung cancer by providing a comprehensive and updated review of immune checkpoint monoclonal antibody-related adverse effects in neuro-ophthalmology irAEs. Through a review of the relevant literature, we intend to illustrate the epidemiology, clinical characteristics, contributory factors, diagnosis, and management of ICI-associated ocular side effects. We will also discuss guidelines and best practice strategies for the prevention, monitoring, and management of these OirAEs.
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Affiliation(s)
- May Ameri
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nagham Al-Zubidi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew G. Lee
- Department of Ophthalmology, The Methodist Hospital, Houston, TX, USA
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7
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Khan M, Talpur AS, Abboud Leon C. A Rare Case of Giant Cell Arteritis After the Administration of Checkpoint Inhibitor Therapy in a Metastatic Renal Cell Carcinoma Patient. Cureus 2023; 15:e50121. [PMID: 38186407 PMCID: PMC10771232 DOI: 10.7759/cureus.50121] [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: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
We present a rare case of metastatic renal cell carcinoma in a patient who developed giant cell arteritis (GCA) after the administration of checkpoint inhibitor therapy with nivolumab and ipilimumab. The patient was initially treated with a combination of nivolumab and ipilimumab, showing a near-complete response with minimal side effects. However, after several cycles of checkpoint inhibitor therapy, the patient developed symptoms consistent with GCA, leading to a halt in the immunotherapy. This report highlights the complexity of managing the adverse effects of immunotherapeutic agents and the importance of a multidisciplinary approach in the management of complications such as GCA.
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Affiliation(s)
- Marjan Khan
- Internal Medicine, Marshfield Medical Center, Marshfield, USA
| | | | - Chady Abboud Leon
- Hematology and Medical Oncology, Marshfield Clinic Health System, Marshfield, USA
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8
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Alsalem AN, Scarffe LA, Briemberg HR, Aaroe AE, Harrison RA. Neurologic Complications of Cancer Immunotherapy. Curr Oncol 2023; 30:5876-5897. [PMID: 37366923 DOI: 10.3390/curroncol30060440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Immunotherapy has revolutionized cancer treatment over the past decade. As it is increasingly introduced into routine clinical practice, immune-related complications have become more frequent. Accurate diagnosis and treatment are essential, with the goal of reduced patient morbidity. This review aims to discuss the various clinical manifestations, diagnosis, treatments, and prognosis of neurologic complications associated with the use of immune checkpoint inhibitors, adoptive T-cell therapies, and T-cell redirecting therapies. We also outline a suggested clinical approach related to the clinical use of these agents.
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Affiliation(s)
- Aseel N Alsalem
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Leslie A Scarffe
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Hannah R Briemberg
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Ashley E Aaroe
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Rebecca A Harrison
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
- Division of Medical Oncology, BC Cancer, University of British Columbia, Vancouver, BC V5Z 4E6, Canada
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9
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Daetwyler E, Zippelius A, Meyer P, Läubli H. Pembrolizumab-induced optic neuropathy - a case report. Front Immunol 2023; 14:1171981. [PMID: 37228591 PMCID: PMC10203429 DOI: 10.3389/fimmu.2023.1171981] [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: 02/22/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Background Immune checkpoint inhibitor (ICI) treatment has become important for treating various cancer types, including Hodgkin's lymphoma. However, ICI can overstimulate the immune system, leading to a broad range of immunological side effects, known as immune-related adverse events (irAEs). Here, we report a case of optic neuropathy caused by pembrolizumab. Case presentation A patient with Hodgkin's lymphoma received pembrolizumab every three weeks. Twelve days after the sixth cycle of pembrolizumab, the patient was admitted to the emergency department with blurred vision, visual field impairment and altered color perception affecting the right eye. The diagnosis of immune-related optic neuropathy was established. Pembrolizumab was stopped permanently and high-dose steroid treatment was immediately started. This emergency treatment led to a satisfactory binocular vision and an improvement of visual acuity testing results. After another 7 months, the left eye was affected with the same symptoms. At this time, only an extended immunosuppressive therapy consisting of high-dose steroid treatment, plasmapheresis, immunoglobulin treatment, retrobulbar injection of steroids and mycophenolate mofetil, successfully reduced the symptoms. Conclusions This case highlights the need for prompt recognition and treatment of rare irAEs, such as optic neuropathy. Urgent treatment with initial high-dose steroid treatment is required to avoid persistent loss of visual acuity. Options for further treatment are mainly based on small case series and case reports. In our case, a retrobulbar injection of steroids in combination with mycophenolate mofetil showed significant success in treating steroid-refractory optic neuropathy.
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Affiliation(s)
- Eveline Daetwyler
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Alfred Zippelius
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Peter Meyer
- Eye Clinic, University Hospital Basel, Basel, Switzerland
| | - Heinz Läubli
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
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10
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Carey AR. Case Report: Successful treatment of external beam radiation-induced optic papillopathy with intravitreal anti-VEGF. FRONTIERS IN OPHTHALMOLOGY 2023; 3:1144241. [PMID: 38983066 PMCID: PMC11182080 DOI: 10.3389/fopht.2023.1144241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/04/2023] [Indexed: 07/11/2024]
Abstract
Three cases of optic disc edema arising from radiation optic neuropathy isolated to the intra-ocular optic nerve following external beam radiation for head and neck squamous cell carcinoma are presented. A literature review of the etiology, presentation, and treatment is included for discussion, along with proposed diagnostic criteria.
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Affiliation(s)
- Andrew R Carey
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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11
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Hirano S, Kojima A, Nakayama Y, Takeda T, Kishimoto T, Takahashi T, Kuwabara S, Mori M. A case report of neuromyelitis optica spectrum disorder induced by pembrolizumab treatment for lung adenocarcinoma: a clinical and immunohistochemical study. BMC Neurol 2022; 22:483. [PMID: 36517738 PMCID: PMC9753385 DOI: 10.1186/s12883-022-02987-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND We report a case of neuromyelitis optica spectrum disorders (NMOSD), who developed after the pembrolizumab treatment, an immune checkpoint inhibitor, against lung adenocarcinoma. The present case is discussed with the lung adenocarcinoma specimen which was stained by aquaporin-4 (AQP4) and with literature review of NMOSD linked to immune checkpoint inhibitors. CASE PRESENTATION A 62-year-old Japanese man presented with acute diencephalic syndrome, left optic neuritis, and myelitis 5 months after initiation of pembrolizumab treatment for lung adenocarcinoma. He was diagnosed with NMOSD based on serum anti-aquaporin-4 (AQP4) antibody positivity. Immunohistochemistry of lung biopsy samples showed AQP4 expression on CD68+ cells. This is the fifth reported case of AQP4+ NMOSD triggered by an immune checkpoint inhibitor and the first with a brain lesion. Four out of five NMOSD cases, including the present case and one case with lung metastasis, had lung cancer. CONCLUSIONS Immune checkpoint inhibitors may trigger AQP4+ NMOSD owing to their molecular similarity to AQP4 expressed in lung and glial tissues. Prompt brain/spinal cord imaging and anti-AQP4 antibody testing may facilitate early diagnosis of immune-mediated adverse event in central nervous system associated with immune checkpoint inhibitors.
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Affiliation(s)
- Shigeki Hirano
- grid.136304.30000 0004 0370 1101Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba Chiba, 260-8670 Japan ,grid.416096.c0000 0004 0569 0258Department of Internal Medicine, Funabashi Central Hospital, Funabashi, Chiba Japan
| | - Akira Kojima
- grid.416096.c0000 0004 0569 0258Department of Internal Medicine, Funabashi Central Hospital, Funabashi, Chiba Japan
| | - Yoko Nakayama
- grid.416096.c0000 0004 0569 0258Department of Ophthalmology, Funabashi Central Hospital, Funabashi, Chiba Japan
| | - Takahiro Takeda
- grid.416698.4Department of Neurology, National Hospital Organization Chiba-Higashi Hospital, Chiba, Chiba Japan
| | - Takashi Kishimoto
- grid.136304.30000 0004 0370 1101Department of Molecular Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba Japan
| | - Toshiyuki Takahashi
- grid.69566.3a0000 0001 2248 6943Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Miyagi Japan ,Department of Neurology, National Hospital Organization Yonezawa National Hospital, Yonezawa, Yamagata Japan
| | - Satoshi Kuwabara
- grid.136304.30000 0004 0370 1101Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba Chiba, 260-8670 Japan
| | - Masahiro Mori
- grid.136304.30000 0004 0370 1101Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba Chiba, 260-8670 Japan
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12
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Husebye ES, Castinetti F, Criseno S, Curigliano G, Decallonne B, Fleseriu M, Higham CE, Lupi I, Paschou SA, Toth M, van der Kooij M, Dekkers OM. Endocrine-related adverse conditions in patients receiving immune checkpoint inhibition: an ESE clinical practice guideline. Eur J Endocrinol 2022; 187:G1-G21. [PMID: 36149449 PMCID: PMC9641795 DOI: 10.1530/eje-22-0689] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022]
Abstract
Immune checkpoint inhibitors (ICI) have revolutionized cancer treatment but are associated with significant autoimmune endocrinopathies that pose both diagnostic and treatment challenges. The aim of this guideline is to provide clinicians with the best possible evidence-based recommendations for treatment and follow-up of patients with ICI-induced endocrine side-effects based on the Grading of Recommendations Assessment, Development, and Evaluation system. As these drugs have been used for a relatively short time, large systematic investigations are scarce. A systematic approach to diagnosis, treatment, and follow-up is needed, including baseline tests of endocrine function before each treatment cycle. We conclude that there is no clear evidence for the benefit of high-dose glucocorticoids to treat endocrine toxicities with the possible exceptions of severe thyroid eye disease and hypophysitis affecting the visual apparatus. With the exception of thyroiditis, most endocrine dysfunctions appear to be permanent regardless of ICI discontinuation. Thus, the development of endocrinopathies does not dictate a need to stop ICI treatment.
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Affiliation(s)
- Eystein S Husebye
- Department of Clinical Science and K.G. Jebsen Center of Autoimmune Diseases, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Correspondence should be addressed to E S Husebye;
| | - Frederik Castinetti
- Aix Marseille Univ, INSERM U1251, Marseille Medical genetics, Department of Endocrinology, Assistance Publique-Hopitaux de Marseille, 13005 Marseille, France
| | - Sherwin Criseno
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Giuseppe Curigliano
- Department of Oncology and Hematology, University of Milan, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Department of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Isabella Lupi
- Endocrine Unit, Pisa University Hospital, Pisa, Italy
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Miklos Toth
- Department of Internal Medicine and Oncology, ENETS Center of Excellence, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | | | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Winges KM, Gordon LK. Neuro-ophthalmic complications of immune checkpoint inhibitor therapy: Current status and future directions. FRONTIERS IN OPHTHALMOLOGY 2022; 2:1044904. [PMID: 38983573 PMCID: PMC11182201 DOI: 10.3389/fopht.2022.1044904] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/24/2022] [Indexed: 07/11/2024]
Abstract
Since 2011, use of immune checkpoint inhibitors (ICI) in cancer immunotherapy dramatically expanded, both alone and in combination with either a different cancer treatment or with two different ICIs. With this increase in use have come a myriad of adverse effects from enhanced immune activation, including ophthalmic and neurologic immune related adverse events (irAE). Neuro-ophthalmic immune related adverse events (NOirAE) associated with use of ICIs are increasingly recognized and their severity may actually limit use of potentially life-saving immunotherapy. NOirAEs comprise a wide variety of presentations involving both the central and peripheral nervous system. They cause afferent or efferent visual dysfunction, including among them optic neuropathy and edema, orbital inflammatory disease, and ocular myasthenia. While treatment for irAEs typically involves immunosuppression with corticosteroids, there is no expert consensus regarding best practices for treatment of NOirAEs and whether to stop ICI immunotherapy for the cancer or not. This state-of-the-art review explores the pathophysiologic basis for NOirAEs, provides a framework for categorizing them within neuro-ophthalmology, and discusses what is needed to close the current knowledge gaps in diagnosis and management of an increasing population of cancer patients requiring neuro-ophthalmic care.
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Affiliation(s)
- Kimberly M. Winges
- Casey Eye Institute Division of Neuro-Ophthalmology, Oregon Health & Science University School of Medicine, Portland, OR, United States
- Veterans Affairs Portland Health Care System, Ophthalmology Department /Operative Care Division, Veterans Health Administration, Portland, OR, United States
| | - Lynn K. Gordon
- Jules Stein Eye Institute Division of Neuro-Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
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Immune Checkpoint Inhibitor-Associated Myositis: A Distinct Form of Inflammatory Myopathy. J Clin Rheumatol 2022; 28:367-373. [PMID: 35696731 DOI: 10.1097/rhu.0000000000001874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Research on the relationship between inflammatory myopathy and malignancy has grown considerably within the last century. Now, the burgeoning field of inflammatory myopathy has yet another player in the mix: immune checkpoint inhibitor-associated myositis (ICI myositis). Immune checkpoint inhibitor-associated myositis is indicated by clinical diagnosis of inflammatory myopathy after initiation of immune checkpoint inhibitor for cancer management. Current literature reflects low prevalence but high mortality associated with ICI myositis, especially when involving myasthenia gravis and myocarditis. Immune checkpoint inhibitor-associated myositis tends to have muscle pain along with weakness, infrequent presentation with dermatitis, or interstitial lung disease and is typically seronegative with scattered, endomysial inflammatory infiltrates on biopsy. The differential diagnosis of ICI myositis includes myasthenia gravis and other neurological immune-related adverse events. Therapeutic approach involves high doses of corticosteroids with a choice of steroid-sparing immunomodulating agent(s) that is primarily driven by expert opinion due to lack of robust research to support one agent over another. There is wide variation in the inclusion criteria for ICI myositis used in previous studies. We review previously used inclusion criteria and suggest an expertise-based classification criterion to provide a standardized definition and allow comparability between studies. There is a critical need for prospective translational and clinical studies that elucidate the pathophysiology of ICI myositis in order to improve evaluation and management of these patients.
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15
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Ocular Inflammation Induced by Immune Checkpoint Inhibitors. J Clin Med 2022; 11:jcm11174993. [PMID: 36078923 PMCID: PMC9456546 DOI: 10.3390/jcm11174993] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Ocular immunotherapy-related adverse events (IRAEs), although rare, can be sight-threatening. Our objective was to analyze ocular IRAEs diagnosed in France from the marketing of immune checkpoint inhibitors (ICPIs) until June 2021 and to review the literature. We collected the cases of 28 patients (36 ocular IRAEs), occurring after an average of 17 weeks (±19). Forty-six percent of patients were treated for metastatic melanoma. Anti-PD1 agents were responsible for 57% of the IRAEs. Anterior uveitis was the most common (44%), followed by panuveitis (28%). Of 25 uveitis cases, 80% were bilateral and 60% were granulomatous. We found one case with complete Vogt-Koyanagi–Harada syndrome and one case of birdshot retinochoroidopathy. The other IRAEs were eight ocular surface disorders, one optic neuropathy, and one inflammatory orbitopathy. Seventy percent of the IRAEs were grade 3 according to the common terminology of AEs. ICPIs were discontinued in 60% of patients and 50% received local corticosteroids alone. The literature review included 230 uveitis cases, of which 7% were granulomatous. The distributions of ICPIs, cancer, and type of uveitis were similar to our cohort. Ocular IRAEs appeared to be easily controlled by local or systemic corticosteroids and did not require routine discontinuation of ICPIs. Further work is still warranted to define the optimal management of ocular IRAEs.
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16
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Mirza J, Sunder SS, Karthikeyan B, Kattel S, Pokharel S, Quigley B, Sharma UC. Echocardiographic and Cardiac MRI Comparison of Longitudinal Strain and Strain Rate in Cancer Patients Treated with Immune Checkpoint Inhibitors. J Pers Med 2022; 12:1332. [PMID: 36013281 PMCID: PMC9410385 DOI: 10.3390/jpm12081332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 01/07/2023] Open
Abstract
Background: Immune checkpoint inhibitor (ICI)-induced cardiac side effects in cancer patients are increasingly being recognized and can be fatal. There is no standardized cardiac imaging test to examine the effects of ICIs in myocardial morphology and function. Objective: To study the utility of echocardiography and cardiac MRI in examining regional and global changes arising from ICI-induced myocarditis and cardiomyopathy in high-risk subjects suspected to have developed ICI cardiomyopathy. Methods: We studied eight consecutive patients referred for cardiac MRI (CMR) from a comprehensive cancer center for suspected ICI-induced myocarditis and compared the data with sixteen age-matched controls. Using newly developed strain analysis algorithms, we measured myocardial strain and strain rates using echocardiography and CMR. Then, we compared the mean longitudinal strain and strain rates derived from echocardiography and CMR in the same ICI-treated cohort of patients (n = 8). They underwent both of these imaging studies with images taken 24−48 h apart and followed up prospectively within the same hospital course. Results: All our cases had preserved ejection fraction (EF) > 50%. Echocardiogram showed reduced mean systolic longitudinal strain (LS, %) (ICI: −12.381 ± 4.161; control: −19.761 ± 1.925; p < 0.001), peak systolic strain rate (SRS, s−1) (ICI: −0.597 ± 0.218; control: −0.947 ± 0.135; p = 0.002) and early diastolic strain rate (SRE, s−1) (ICI: 0.562 ± 0.295; control: 1.073 ± 0.228; p = 0.002) in ICI-treated cases. Direct comparison between the echocardiogram vs. CMR obtained within the same hospital course demonstrated strong a correlation of LS scores (r = 0.83, p = 0.012) and SRS scores (r = 0.71, p = 0.048). The Bland−Altman plots showed that 95% of the data points fitted within the ±1.96 SD of the mean difference, suggesting an agreement among these two imaging modalities. Conclusion: In this feasibility cohort study, both echocardiography- and CMR-based strain indices illustrate changes in myocardial contractility and relaxation suggestive of ICI-induced cardiomyopathy. Our data, after validation in a larger cohort, can form the basis of myocardial imaging in cancer patients treated with ICIs.
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Affiliation(s)
- Jibran Mirza
- Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY 14203, USA
| | - Sunitha Shyam Sunder
- Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY 14203, USA
| | - Badri Karthikeyan
- Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY 14203, USA
| | - Sharma Kattel
- Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY 14203, USA
| | - Saraswati Pokharel
- Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA
| | - Brian Quigley
- Clinical and Research Institute on Addictions, University at Buffalo, Buffalo, NY 14203, USA
| | - Umesh C. Sharma
- Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY 14203, USA
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17
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Wang J, Xiao X, Dong X, Wu G, Wang X, Zhang R. Anti-PD-1 sintilimab-induced bilateral optic neuropathy in non-small cell lung cancer: A case report and literature review. Front Oncol 2022; 12:931074. [PMID: 36016624 PMCID: PMC9396260 DOI: 10.3389/fonc.2022.931074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/15/2022] [Indexed: 01/03/2023] Open
Abstract
Anti-PD-1/PD-L1 immunotherapy reactivates T-cell activity to boost the antitumor effect and may trigger autoimmune toxicity in various organ systems involving eyeball and periocular structures at the same time. The rarity of ocular immune-related adverse events should not prevent us from paying attention to this issue because of the bad consequences of visual impairment. This is the first case report of anti-PD-1 sintilimab-induced bilateral optic neuropathy in a 76-year-old man with squamous non-small cell lung cancer (NSCLC). The patient presented with sudden vision blurring without pain in both eyes after three therapeutic cycles of sintilimab plus chemotherapy. Based on the ophthalmic examination, laboratory, and radiological results, our patient was diagnosed with optic neuropathy complication secondary to anti-PD-1 sintilimab treatment. Consequently, sintilimab was held and systemic steroids were administered. The follow-up review showed that the vision recovered and the size of the primary tumor continued to decrease with the response assessment as the partial response. In conclusion, this case report suggested that patients with NSCLC undergoing anti-PD-1/PD-L1 therapy should be closely monitored for ophthalmic assessment and alert to the occurrence of sintilimab-induced optic neuropathy.
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Affiliation(s)
- Jian Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyue Xiao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaorong Dong
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Wu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinghua Wang
- Department of Ophthalmology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xinghua Wang, ; Ruiguang Zhang,
| | - Ruiguang Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xinghua Wang, ; Ruiguang Zhang,
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18
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Kizza J, Lu RJ, Zuflacht J, Bouffard M. Clinical Reasoning: A 48-Year-Old Woman With 6 Months of Vivid Visual Hallucinations. Neurology 2022; 99:166-171. [PMID: 35577571 PMCID: PMC9421773 DOI: 10.1212/wnl.0000000000200806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/14/2022] [Indexed: 11/15/2022] Open
Abstract
Visual hallucinations are frequently encountered in clinical practice. It is critical for neurologists, particularly those in training, to develop a systematic approach for evaluating patients presenting with such unique and often perplexing symptoms. In this study, we present the case of a 48-year-old woman who developed vivid visual hallucinations after receiving nivolumab for melanoma. We discuss the broad differential diagnosis for visual hallucinations and how history and examination can guide one's evaluation.
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Affiliation(s)
- Jennifer Kizza
- From the Harvard Medical School (J.K., R.J.L.); Hospital of University of Pennsylvania (J.Z.); and Beth Israel Deaconess Medical Center (M.B.)
| | - Richard J Lu
- From the Harvard Medical School (J.K., R.J.L.); Hospital of University of Pennsylvania (J.Z.); and Beth Israel Deaconess Medical Center (M.B.)
| | - Jonah Zuflacht
- From the Harvard Medical School (J.K., R.J.L.); Hospital of University of Pennsylvania (J.Z.); and Beth Israel Deaconess Medical Center (M.B.).
| | - Marc Bouffard
- From the Harvard Medical School (J.K., R.J.L.); Hospital of University of Pennsylvania (J.Z.); and Beth Israel Deaconess Medical Center (M.B.)
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19
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Delayed-Onset Inflammatory Optic Nerve Sheath Mass and Perineuritis Following Cessation of Ipilimumab and Nivolumab Therapy. Ophthalmic Plast Reconstr Surg 2022; 38:e119-e122. [DOI: 10.1097/iop.0000000000002170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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20
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Baj J, Forma A, Kobak J, Tyczyńska M, Dudek I, Maani A, Teresiński G, Buszewicz G, Januszewski J, Flieger J. Toxic and Nutritional Optic Neuropathies—An Updated Mini-Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053092. [PMID: 35270784 PMCID: PMC8910489 DOI: 10.3390/ijerph19053092] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/27/2022] [Accepted: 03/03/2022] [Indexed: 12/20/2022]
Abstract
Optic neuropathies constitute a group of conditions with various etiologies and might be caused by different factors; we can distinguish the genetic and acquired causes of optic neuropathies. Even though the symptoms are not highly specific, this condition is primarily characterized by unilateral or bilateral vision loss with worsening color detection. The loss may be acute or gradual depending on the causation. In this article, we included a specification of toxic optic neuropathy (TON) mainly triggered by alcohol abuse and also the usage of other substances, including drugs or methanol, as well as intoxication by metals, organic solvents, or carbon dioxide. Nutritional deficiencies, vitamin absorption disorder, and anemia, which usually appear during excessive alcohol intake, and their effect on the etiology of the optic neuropathy have been likewise discussed.
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Affiliation(s)
- Jacek Baj
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland; (J.B.); (A.M.)
| | - Alicja Forma
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
- Correspondence:
| | - Joanna Kobak
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Magdalena Tyczyńska
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Iga Dudek
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Amr Maani
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland; (J.B.); (A.M.)
| | - Grzegorz Teresiński
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Grzegorz Buszewicz
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Jacek Januszewski
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland;
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21
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Živković SA, Al-Lahham T. Neurologic Complications of Immune Checkpoint Inhibitors. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The clinical use of cancer immunotherapy with immune checkpoint inhibitors has transformed the management of cancer and added another effective treatment option for different types of malignancies. The blockade of immune checkpoint pathways triggers an enhanced immune response leading to cancer regression but may also lead to autoimmune toxicities or immune-related adverse events, which may involve skin, endocrine, respiratory, gastrointestinal or neurologic manifestations. Clinically relevant neurologic complications involving the central and/or peripheral nervous system affect up to 1% of patients treated with immune checkpoint inhibitors and may be associated with significant morbidity and mortality. Common neurologic complications include aseptic meningitis and encephalitis, hypophysitis, myasthenia, myositis and neuropathies. Neurologic immune-related adverse events after immune checkpoint inhibition should be distinguished from cancer progression or other complications of cancer therapy (e.g. infections). The treatment of neurologic complications may include holding or withdrawing cancer immunotherapy, anti-inflammatory and immunosuppressive therapies with corticosteroids and steroid-sparing agents, immunomodulation with intravenous immune globulin or plasmapheresis and symptomatic treatment (e.g. antiepileptic medications, pain medications).
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22
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Palma Dos Reis AF, Hennig I, Wilcock A. Immune checkpoint inhibitors: current status. BMJ Support Palliat Care 2021:bmjspcare-2021-002954. [PMID: 34130996 DOI: 10.1136/bmjspcare-2021-002954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
The use of immune checkpoint inhibitors (ICIs) is growing rapidly in oncology and palliative care clinicians and other generalists will increasingly see patients who are receiving, or who have received ICI. For optimal care, it is important that clinicians have a basic understanding of the unique nature of ICI as anticancer treatments, including patterns of response, potential issues with concurrent corticosteroid use and the wide range of possible immune-related adverse effects (IrAEs). This paper, informed by a recent literature search, provides a succinct yet comprehensive overview of ICI, with a particular focus on IrAE, highlighting that some are potentially life-threatening and/or can develop a long time, sometimes years, after even a short course of an ICI.
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Affiliation(s)
- Ana Filipa Palma Dos Reis
- Serviço de Oncologia, Hospital Santo António dos Capuchos, Lisboa, Portugal
- Anatomia, Universidade Nova de Lisboa Faculdade de Ciências Médicas de Lisboa, Lisboa, Portugal
| | - Ivo Hennig
- Clinical Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Wilcock
- Palliative Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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23
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Abstract
The proliferation of targeted anticancer agents over the last two decades has revolutionized cancer treatment and improved survival in many previously refractory malignancies. However, many agents are associated with characteristic ophthalmic adverse effects. It is important that ophthalmologists recognize and maintain a high index of suspicion for these side effects in patients on targeted therapy. Most ophthalmic adverse effects can be treated with specific ocular therapy without discontinuation of cancer treatment, although it is important to be aware of the life-threatening and vision-threatening circumstances that would require therapy cessation in conjunction with the patient's oncologist. This review aims to summarize the ophthalmic adverse effects of targeted and hormonal anticancer agents and briefly describe their management.
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