Thyrotoxicosis and Adrenocortical Hormone Deficiency During Immune-checkpoint Inhibitor Treatment for Malignant Melanoma

Improved overall survival in patients developing endocrine toxicity during treatment with nivolumab for advanced non-small cell lung cancer in a prospective study

PURPOSE

Immune checkpoint inhibitors (ICPIs) disrupting PD-1/PD-L1 axis have revolutionized the management of advanced non-small cell lung cancer (NSCLC). Some studies identified the development of endocrine toxicity as predictor of better survival in cancer patients treated with ICPIs. The aim of study was to evaluate survival and new onset of immune-related endocrine adverse events (irAEs) in patients treated with nivolumab for advanced NSCLC.

METHODS

In a prospective study, 73 patients with previously treated advanced NSCLC received nivolumab in monotherapy. Blood samples were collected at each cycle to monitor thyroid autoimmunity, thyroid, adrenal and somatotroph axes, while thyroid morphology was evaluated by ultrasonography.

RESULTS

An impaired thyroid function was recorded in 23.4% of patients (n = 15). Eight patients developed asymptomatic transient thyrotoxicosis (ATT) evolving to hypothyroidism in 50% of cases. In addition, seven patients developed overt hypothyroidism without ATT and with negative autoantibodies. Patients who developed hypothyroidism proved to have better overall survival (OS) as compared with non-developers at both univariate (p = 0.021) and multivariate analyses (p = 0.023). The survival curve of patients with reduced IGF-I at baseline, or displaying its reduction during the follow-up, showed significantly reduced median survival compared to patients with normal/high IGF-I levels (p = 0.031).

CONCLUSIONS

Thyroid function abnormalities are the major irAEs in patients treated with nivolumab, and hypothyroidism onset is associated with prolonged survival. Our findings indicate that the development of hypothyroidism is a positive predictive biomarker of nivolumab antitumor efficacy in patients with NSCLC. Low IGF-I levels could represent a negative prognostic factor during nivolumab therapy.

Immune checkpoint inhibitor-induced isolated adrenocorticotropic hormone deficiency: a systematic review

Background

Immune checkpoint inhibitor-induced isolated adrenocorticotropic hormone deficiency (IAD) is a rare but potentially fatal disease.

Methods

We comprehensively searched the PubMed database and made a systematic review of immune checkpoint inhibitor-induced isolated adrenocorticotropic hormone deficiency. If the status of other anterior pituitary hormones was not mentioned, the case was excluded.

Results

We identified 123 cases diagnosed as immune checkpoint inhibitor-induced IAD, consisting of 44 female and 79 male patients. The average age of these patients was 64.3 ± 12.6 years old, and 67.5% were 60 years old or above. The majority (78.9%) of these patients received anti-programmed cell death protein-1 (anti-PD-1) antibodies or anti-programmed cell death ligand 1 (anti-PD-L1) antibodies or both, and 19.5% received combined therapy, sequential therapy, or both. A total of 26 patients received anti-cytotoxic T lymphocyte antigen 4 antibodies (anti-CTLA-4). The median ICI treatment cycle before the diagnosis of adrenal insufficiency was 8 (6, 12), and the median ICI treatment duration before the diagnosis of adrenal insufficiency was 6 (4, 8) months. Eleven cases developed IAD 1 to 11 months after discontinuation of ICIs. Fatigue and appetite loss were the most common symptoms, and surprisingly, there were two asymptomatic cases of IAD. Most patients (88 cases) had normal pituitary magnetic resonance imaging, only 14 cases reported mild atrophy or swelling pituitary gland, and 21 cases reported no imaging results. Most diagnoses were made by basal hormone levels, and pituitary stimulation tests were performed in only a part of the cases. No cases had been reported of discontinuation of ICI use due to IAD nor had there been any deaths due to IAD.

Conclusion

IAD was predominant in elderly male patients mainly receiving anti-PD-1 or anti-PD-L1 antibodies. It was sometimes difficult to recognize IAD at first glance since non-specific symptoms were common and asymptomatic cases of IAD were also reported. Although IAD can be deadly, it usually does not affect the continued use of ICIs.

Follow-up Care for Patients Receiving Immune Checkpoint Inhibitors

The rapid advances in cancer immunotherapy using immune checkpoint inhibitors (ICIs) have led to significantly improved survival of patients. But at the same time, it also associates with multiple immune-related adverse events (irAEs). The irAEs can affect a wide range of organs, and induce nonspecific symptoms with delayed onset and prolonged duration that is easily neglected, which may lead to life-threatening disorders. Therefore, follow-up care for patients receiving ICIs for irAEs management has become an essential competency in cancer nursing. There are several guidelines about the management of irAEs, which focused on diagnosis, grading, and treatment. However, studies on relevant follow-up care are rare. Nurses play an important role in follow-up care, whose relevant knowledge and skills are indispensable. Combined with domestic and foreign guidelines and related studies, this paper reviewed the occurrence and characteristics of irAEs and highlighted the contents, timing, models, and effects of follow-up care for patients receiving ICIs, to provide a reference for clinical nursing practice and improve the safety of immunotherapy for patients.

Isolated ACTH deficiency induced by cancer immunotherapy: a systematic review

Immunotherapy with immune checkpoint inhibitor (ICI) monoclonal antibodies has shown to be an effective therapeutic alternative in several malignant tumors. However, adverse effects related to an activation of the immune system may accompany ICI therapy. Among the immune-related adverse events (irAEs) are autoimmune endocrine adverse effects, such as thyroiditis, and hypophysitis. Secondary adrenal insufficiency due to isolated ACTH deficiency (IAD) has also been recently reported to be associated with ICI antibodies. We carried out a systematic review of IAD cases induced by cancer immunotherapy published to date using PubMed's database. We selected 35 articles that reported 60 cancer patients diagnosed with IAD induced by ICI therapy. The prevalence was higher in men (ratio 1.6/1). Mean age at diagnosis was 63.2 ± 11.6 (range,30-87). Melanoma was the tumor most commonly reported (35%) followed by lung (28.3%) and kidney cancer (18.3%). The ICI monoclonal antibody most frequently associated was nivolumab in monotherapy (60%), followed by pembrolizumab (18.3%). Median (IQR) time to develop IAD after starting ICI therapy was 6 (4-8) months. The main symptoms at IAD diagnosis were fatigue (82.8%) and anorexia (67.2%). Hyponatremia (68%) and eosinophilia (31.8%) were the laboratory abnormalities most frequently associated with IAD. Pituitary magnetic resonance imaging (MRI) was normal in most patients (93%). Thyroiditis was the most prevalent (35%) endocrine irAE associated with IAD. In conclusion, ICI-induced IAD is a rare and potentially life-threatening condition that must be taken into account whenever treatment with immunotherapy in cancer patients is started due to their potential serious prognostic implications.

Fast Independent Component Analysis Algorithm-Based Diagnosis of L5 Nerve Root Compression and Changes of Brain Functional Areas Using 3D Functional Magnetic Resonance Imaging

In this paper, the application of 3-dimensional (3D) functional magnetic resonance imaging (FMRI) in the diagnosis of the 5^th lumbar (L5) nerve root compression and brain functional areas in patients with lumbar disc herniation (LDH) was analyzed. The traditional fast independent component analysis (Fast ICA) algorithm was optimized based on the modified whitening matrix to establish a new type of Modified-Fast ICA (M-Fast ICA) algorithm that was compared with the introduced traditional Fast ICA and ICA. M-Fast ICA was applied to the 3D FMRI diffusion tensor imaging (DTI) evaluation of 65 patients with L5 nerve root pain due to LDH (group A) and 50 healthy volunteers (group B). The values of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) in the lumbar nerve roots (L3, L4, L5, and the 1^st sacral vertebra (S1)) were recorded among subjects from the two groups. Besides, the score of edema degree in the lumbar nerve roots (L5 and S1) and activity of brain functional areas were also recorded among all subjects of the two groups. The results showed that the mean square error of M-Fast ICA was smaller than that of traditional Fast ICA and ICA, while its signal-to-noise ratio (SNR) was greater than that of Fast ICA and ICA (P < 0.05). The FA of L5 and S1 nerve roots in patients of group A was sharply lower than the values of group B, while the ADC of patients in group A was greater than that of the control group (P < 0.05). Besides, the score of edema in L5 and S1 nerve roots of patients in group A increased in contrast to group B (P < 0.05). The brain areas were activated after surgery including bilateral temporal lobe, left thalamus, splenium of corpus callosum, and right internal capsule. In conclusion, the 3D image denoising performance of M-Fast ICA optimized and constructed in this study was superior to that of the traditional Fast ICA and ICA. The FA of patients with L5 nerve root pain due to LDH decreased steeply, while the ADC increased dramatically. L5 nerve root pain caused by LDH resulted in changes in brain functional areas of the patients to inhibit the resting state default network activity, and the corresponding brain functional areas could be activated through treatment.

Isolated Adrenocorticotropic Hormone Deficiency Associated with Severe Hyperkalemia During Pembrolizumab Therapy in a Patient with Ureteral Cancer and an Ileal Conduit: A Case Report and Literature Review

Patient: Female, 78-year-old

Final Diagnosis: Isolated adrenocorticotropic hormone deficiency

Symptoms: Anorexia • general weakness • muscle pain

Medication: Hydrocortisone

Clinical Procedure: Endocrine test

Specialty: Endocrinology and Metabolic

Immune checkpoint inhibitors-induced eosinophilic pneumonia: A case report

A 78‐year‐old male with renal cell carcinoma was treated with combined immunotherapy of nivolumab and ipilimumab. After four courses of the treatment, a chest computed tomography (CT) revealed newly formed ground‐glass opacities (GGOs) in both the lower lung lobes; drug‐induced pneumonia was speculated. Eosinophil counts were elevated in both peripheral blood and bronchoalveolar lavage fluid. Both the immune checkpoint inhibitors (ICIs) were discontinued, following which the chest CT findings improved. Based on these findings, a diagnosis of ICI‐induced eosinophilic pneumonia was made. Hence, clinicians should be wary of the risk of eosinophilic pneumonia during ICI‐anticancer therapy.

Predictive and sensitive biomarkers for thyroid dysfunctions during treatment with immune-checkpoint inhibitors

Immune‐related adverse events (irAEs) are often seen during immune‐checkpoint inhibitor (ICI) treatment of various malignancies. Endocrine irAEs including thyroid dysfunctions are the most common irAEs, but their biomarkers remain unclear. In order to identify individuals who are susceptible to thyroid irAE for earlier diagnosis and appropriate follow‐up, the current study is aimed to investigate biomarkers of thyroid irAE. Herein, patients with advanced malignant diseases who received ICIs treatment were prospectively studied. Clinical and laboratory examination, thyroid function, and autoantibodies were evaluated at baseline, and every 4 wk after first treatment with ICIs. Cytokines/chemokines were measured at baseline and at 4 wk. In vivo effects of ICIs on experimental autoimmune thyroiditis were evaluated. Twenty‐six patients with malignant diseases who received ICIs treatment were enrolled in the study. Patients were divided into two groups: those who developed thyroid irAE, and those without irAEs. Comparing the two groups, early increase (≤4 wk) in serum thyroglobulin (Tg) levels and thyroid autoantibodies was seen in thyroid irAE (P < .05). Notably, higher levels of serum IL‐1β, IL‐2, and GM‐CSF at baseline, and early decrease of IL‐8, G‐CSF, and MCP‐1 were significantly associated in the development of thyroid irAE (P < .05). In vivo effects of anti‐PD‐1 antibody on deterioration of mice experimental thyroiditis were seen. In conclusion, early change in Tg, thyroid autoimmunity, and cytokine levels might indicate development of thyroid irAE. Pre‐existing thyroid autoimmunity might be involved with the development of thyroid irAE. Potential application of these factors as surrogate biomarkers for tumor therapy was indicated.

Isolated adrenocorticotropic hormone deficiency and thyroiditis associated with nivolumab therapy in a patient with advanced lung adenocarcinoma: a case report and review of the literature

Introduction

Immune checkpoint inhibitors are a promising class of anticancer drugs. The clinical benefits afforded by immune checkpoint inhibitors can be accompanied by immune-related adverse events that affect multiple organs, and endocrine immune-related adverse events include thyroiditis and hypophysitis. Hypophysitis is less frequent and has a less severe clinical presentation in patients treated with other immune checkpoint inhibitors, such as nivolumab, pembrolizumab, and atezolizumab, than in those treated with ipilimumab. However, studies have described isolated adrenocorticotropic hormone deficiency cases associated with nivolumab, pembrolizumab, and atezolizumab therapy, most of which occurred during the course of immune checkpoint inhibitor therapy. We report a rare case of patient with isolated adrenocorticotropic hormone deficiency that occurred after nivolumab therapy.

Case presentation

A 69-year-old Japanese woman with advanced lung adenocarcinoma developed painless thyroiditis with transient elevations of serum thyroid hormones during 3 months of cancer treatment with nivolumab and began thyroid hormone replacement therapy for subsequent primary hypothyroidism. Four months after nivolumab therapy was discontinued, she developed isolated adrenocorticotropic hormone deficiency; corticosteroid replacement therapy relieved her secondary adrenal insufficiency symptoms, such as anorexia and fatigue. Human leukocyte antigen typing revealed the presence of DRB1*04:05-DQB1*04:01-DQA1*03:03 and DRB1*09:01-DQB1*03:03-DQA1*03:02 haplotypes, which increase susceptibility to autoimmune polyendocrine syndrome associated with thyroid and pituitary disorders in the Japanese population.

Conclusions

Our patient developed thyroiditis during cancer treatment with nivolumab and subsequently exhibited isolated adrenocorticotropic hormone deficiency 4 months after discontinuing the drug. Administration of nivolumab in combination with a genetic predisposition to polyglandular autoimmunity probably caused both the thyroiditis and hypophysitis, resulting in primary hypothyroidism and isolated adrenocorticotropic hormone deficiency, respectively, in our patient. The present case highlights the need for physicians to be aware that endocrine immune-related adverse events, including hypophysitis, can occur more than several months after discontinuing a drug.

Adverse Effects of Immune Checkpoint Inhibitors (Programmed Death-1 Inhibitors and Cytotoxic T-Lymphocyte-Associated Protein-4 Inhibitors): Results of a Retrospective Study

In recent years the use of immunomodulating therapy to treat various cancers has been on the rise. Three checkpoint inhibitors have been approved by the Food and Drug Administration (ipilimumab, pembrolizumab and nivolumab). The use of these drugs comes with serious adverse events related to excessive immune activation, collectively known as immune-related adverse events (irAEs). We conducted a system-based review of 139 case reports/case series that have described these adverse events between January 2016 and April 2018, found in the PubMed database. There was a broad spectrum of presentations, doses and checkpoint inhibitors used. The most common check point inhibitor observed in our literature review was nivolumab. The most common adverse effects encountered were colitis (14/139), hepatitis (11/139), adrenocorticotropic hormone insufficiency (12/139), hypothyroidism (7/139), type 1 diabetes (22/139), acute kidney injury (16/139) and myocarditis (10/139). The treatment most commonly consisted of cessation of the immune checkpoint inhibitor, initiation of steroids and supportive therapy. This approach provided a complete resolution in a majority of cases; however, there were many that developed long-term adverse events with deaths reported in a few cases. The endocrine system was the mostly commonly affected with the development of type 1 diabetes mellitus or diabetic ketoacidosis being the most frequently reported adverse events. While immunomodulating therapy is a significant advance in the management of various malignancies, it is capable of serious adverse effects. Because the majority of the cases developed pancreatic dysfunction within five cycles of therapy, in addition to the evaluation of other systems, pancreatic function should be closely monitored to minimize adverse impact on patients.

Immune-Related Adverse Events From Immunotherapy: Incorporating Care Step Pathways to Improve Management Across Tumor Types

Immune checkpoint inhibitor (ICI) therapy provides a valuable treatment option for many cancer patients but is associated with immune-related adverse events (irAEs) that can involve any organ system. Managing irAEs can be a challenge, as these AEs differ from those associated with conventional chemotherapy in both appearance and care. Prompt and successful irAE management is important for patient health and the maintenance of effective therapy. A group of advanced practice providers has developed Care Step Pathways (CSPs) to improve the management of irAEs (see Appendix and aimwithimmunotherapy.org). These CSPs, which combine established guidelines with practical experience, provide information on assessing, grading, and managing irAEs. Proactive strategies, implementation tactics, patient education points, and "red flags" are also featured. This article provides a brief summary of ICI therapies currently used in oncology and an overview of irAEs that may occur during treatment. The importance of medication reconciliation and a thorough baseline assessment is stressed, and detailed information on baseline clinical and laboratory tests is provided. Specific CSPs for several irAEs, such as gastrointestinal toxicity, adrenal insufficiency, nephritis, and neuropathy, are reviewed in detail. As these CSPs illustrate, advanced practice providers are well positioned to play a key role in collaborative care for oncology patients, particularly with respect to providing in-depth patient education and "owning" AE management.