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Ladouceur A, Ezdoglian A, Sparks JA, Hudson M, Jamal S, Clifford A, Roberts J, Ye C. The Utility of Laboratory Investigations for the Assessment and Management of Rheumatic Immune Related Adverse Events. Rheum Dis Clin North Am 2024; 50:181-199. [PMID: 38670720 DOI: 10.1016/j.rdc.2024.01.003] [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] [Indexed: 04/28/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have greatly improved survival of several cancers with historically very poor prognosis. ICIs act by stimulating the patient's own immune system to fight cancer. Simultaneously, this immune activation can lead to immune-related adverse events (irAEs), including rheumatic manifestations (Rh-irAEs). Rh-irAEs mimic primary rheumatic diseases including arthritis, polymyalgia rheumatica, myositis, vasculitis, sarcoidosis, and sicca. This article summarizes the latest evidence regarding the utility of laboratory investigations in Rh-irAEs.
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Affiliation(s)
- Alexandra Ladouceur
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - Aiarpi Ezdoglian
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, VU University Medical Center (VUmc), De Boelelaan 1118, Amsterdam 1081 HZ, the Netherlands
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Suite 6016U, Boston, MA 02115, USA
| | - Marie Hudson
- Division of Rheumatology, Department of Medicine, Jewish General Hospital and McGill University, Lady Davis Institute for Medical Research, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - Shahin Jamal
- Arthritis Research Canada, Department of Medicine, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel Street, Ste 8205B, Vancouver, British Columbia V5Z 1M9, Canada
| | - Alison Clifford
- Faculty of Medicine & Dentistry, Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, Alberta T6G 2G3, Canada
| | - Janet Roberts
- Division of Rheumatology, Department of Medicine, Queen Elizabeth II Health Sciences Center and Dalhousie University, Nova Scotia rehabilitation and Arthritis Centre, Arthritis Research Canada; Lady Davis Institute for Medical Research, 1341 Summer Street, Halifax, Nova Scotia B3H 4K4, Canada
| | - Carrie Ye
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, Alberta T6G 2G3, Canada.
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Ponce A, Frade-Sosa B, Sarmiento-Monroy JC, Sapena N, Ramírez J, Azuaga AB, Morlà R, Ruiz-Esquide V, Cañete JD, Sanmartí R, Gómez-Puerta JA. Imaging Findings in Patients with Immune Checkpoint Inhibitor-Induced Arthritis. Diagnostics (Basel) 2022; 12:1961. [PMID: 36010310 PMCID: PMC9406920 DOI: 10.3390/diagnostics12081961] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 01/27/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)-induced arthritis is an increasingly recognized adverse event in patients with oncologic disease during immunotherapy. Four patterns are well described, including rheumatoid arthritis (RA)-like, polymyalgia rheumatica (PMR)-like, psoriatic arthritis (PsA)-like, and oligo-monoarthritis, among others. Despite better clinical recognition of these syndromes, information about the main imaging findings is limited. METHODS We conducted a retrospective observational study including all adult patients referred to the Rheumatology Department of a single-center due to ICI-induced arthritis who underwent imaging studies [ultrasound (US), magnetic resonance imaging (MRI), and 18F-FDG PET/CT)] between January 2017 and January 2022. RESULTS Nineteen patients with ICI-induced arthritis with at least one diagnostic imaging assessment were identified (15 US, 4 MRI, 2 18F-FDG PET/CT). Most patients were male (84.2%), with a median age at inclusion of 73 years. The main underlying diagnoses for ICI treatment were melanoma in five cases. The distribution of ICI-induced arthritis was as follows: PMR-like (5, 26.2%), RA-like (4, 21.1%), PsA-like (4, 21.1%), and others (6, 31.6%). All RA-like patients had US findings indistinguishable from conventional RA patients. In addition, 3/5 (60%) of PMR-like patients had significant involvement of the hands and wrists. Abnormal findings on MRI or PET-CT were reported by clinical symptoms. No erosions or myofascitis were seen. CONCLUSIONS ICI-induced arthritis patients present inflammatory patterns on imaging studies similar to conventional inflammatory arthropathies, and therefore these syndromes should be followed carefully and treated according to these findings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - José A. Gómez-Puerta
- Department of Rheumatology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
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Salamaliki C, Solomou EE, Liossis SNC. Immune Checkpoint Inhibitor-Associated Scleroderma-Like Syndrome: A Report of a Pembrolizumab-Induced "Eosinophilic Fasciitis-Like" Case and a Review of the Literature. Rheumatol Ther 2020; 7:1045-1052. [PMID: 33067734 PMCID: PMC7695772 DOI: 10.1007/s40744-020-00246-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/08/2020] [Indexed: 12/20/2022] Open
Abstract
Immune checkpoint inhibitors are a promising new therapeutic strategy in oncology that aims to eliminate cancer cells by enhancing patients' immune response against tumor antigens. Despite their beneficial effects, immune checkpoint inhibitors are also responsible for a plethora of autoimmune manifestations, known as immune-related adverse events. We present a case of eosinophilic fasciitis-like disorder in an 81-year-old patient treated with the programmed death cell protein 1 inhibitor pembrolizumab for non-small-cell lung cancer. The patient developed characteristic indurated skin lesions in his limbs after 1½ years of treatment with pembrolizumab and a typical “groove sign.” Raynaud’s syndrome was absent. A full-thickness biopsy confirmed the clinical diagnosis of an “EF-like” condition. Neither peripheral eosinophilia nor eosinophilic infiltrates in the skin biopsy were found. His symptoms improved after a 2.5-month CPI discontinuation and treatment with 16 mg of methylprednisolone slowly tapered to a dose of 4 mg. Eosinophilic fasciitis is a rare immune-related adverse event of CPI treatment; our literature search identified only 12 cases that fulfill the criteria of EF in patients receiving CPIs.
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Affiliation(s)
- Christina Salamaliki
- Division of Rheumatology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Elena E Solomou
- Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Stamatis-Nick C Liossis
- Division of Rheumatology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece.
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Kostine M, Finckh A, Bingham CO, Visser K, Leipe J, Schulze-Koops H, Choy EH, Benesova K, Radstake TRDJ, Cope AP, Lambotte O, Gottenberg JE, Allenbach Y, Visser M, Rusthoven C, Thomasen L, Jamal S, Marabelle A, Larkin J, Haanen JBAG, Calabrese LH, Mariette X, Schaeverbeke T. EULAR points to consider for the diagnosis and management of rheumatic immune-related adverse events due to cancer immunotherapy with checkpoint inhibitors. Ann Rheum Dis 2020; 80:36-48. [PMID: 32327425 PMCID: PMC7788064 DOI: 10.1136/annrheumdis-2020-217139] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
Background Rheumatic and musculoskeletal immune-related adverse events (irAEs) are observed in about 10% of patients with cancer receiving checkpoint inhibitors (CPIs). Given the recent emergence of these events and the lack of guidance for rheumatologists addressing them, a European League Against Rheumatism task force was convened to harmonise expert opinion regarding their identification and management. Methods First, the group formulated research questions for a systematic literature review. Then, based on literature and using a consensus procedure, 4 overarching principles and 10 points to consider were developed. Results The overarching principles defined the role of rheumatologists in the management of irAEs, highlighting the shared decision-making process between patients, oncologists and rheumatologists. The points to consider inform rheumatologists on the wide spectrum of musculoskeletal irAEs, not fulfilling usual classification criteria of rheumatic diseases, and their differential diagnoses. Early referral and facilitated access to rheumatologist are recommended, to document the target organ inflammation. Regarding therapeutic, three treatment escalations were defined: (1) local/systemic glucocorticoids if symptoms are not controlled by symptomatic treatment, then tapered to the lowest efficient dose, (2) conventional synthetic disease-modifying antirheumatic drugs, in case of inadequate response to glucocorticoids or for steroid sparing and (3) biological disease-modifying antirheumatic drugs, for severe or refractory irAEs. A warning has been made on severe myositis, a life-threatening situation, requiring high dose of glucocorticoids and close monitoring. For patients with pre-existing rheumatic disease, baseline immunosuppressive regimen should be kept at the lowest efficient dose before starting immunotherapies. Conclusion These statements provide guidance on diagnosis and management of rheumatic irAEs and aim to support future international collaborations.
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Affiliation(s)
- Marie Kostine
- Rheumatology, University Hospital of Bordeaux, Bordeaux, France
| | - Axel Finckh
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | | | - Karen Visser
- Rheumatology, Haga Hospital, Den Haag, The Netherlands
| | - Jan Leipe
- Department of Medicine V, Division of Rheumatology, University Hospital Centre, Mannheim, Germany.,Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Hendrik Schulze-Koops
- Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Ernest H Choy
- Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
| | | | | | - Andrew P Cope
- Academic Department of Rheumatology, King's College London, London, UK
| | - Olivier Lambotte
- Internal Medicine and Clinical Immunology, Hopital Bicetre, Le Kremlin-Bicetre, France
| | | | - Yves Allenbach
- Internal Medicine and Clinical Immunology, Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France
| | - Marianne Visser
- EULAR PARE Patient Research Partners, Amsterdam, The Netherlands
| | - Cindy Rusthoven
- EULAR PARE Patient Research Partners, Amsterdam, The Netherlands
| | | | - Shahin Jamal
- Rheumatology, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - James Larkin
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - John B A G Haanen
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | | | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, Le Kremlin Bicêtre, France.,3Université Paris-Sud, Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
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