Post-shingles granulomatous dermatosis related to anti-programmed cell death 1

Herpes zoster in patients with solid tumors treated with immune checkpoint inhibitors

Tweetable abstract

Herpes zoster (HZ) is a vaccine-preventable disease, but the role of the vaccine in cancer patients during immunotherapy (ICIs) is still unknown. The clinical and economic consequences of HZ and the increased use of ICIs require a greater awareness by the oncologist.

Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update

PURPOSE

To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with immune checkpoint inhibitor (ICPi) therapy.

METHODS

A multidisciplinary panel of medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to update the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 through 2021.

RESULTS

A total of 175 studies met the eligibility criteria of the systematic review and were pertinent to the development of the recommendations. Because of the paucity of high-quality evidence, recommendations are based on expert consensus.

RECOMMENDATIONS

Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to the organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, except for some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert ≤ grade 1. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids. Corticosteroids should be tapered over the course of at least 4-6 weeks. Some refractory cases may require other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, except for endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines.

Infections due to dysregulated immunity: an emerging complication of cancer immunotherapy

Immune checkpoint inhibitors (ICIs) have revolutionised cancer treatment. However, immune-related adverse events (irAEs) are a common side effect which can mimic infection. Additionally, treatment of irAEs with corticosteroids and other immunosuppressant agents can lead to opportunistic infection, which we have classed as immunotherapy infections due to immunosuppression. However, emerging reports demonstrate that some infections can be precipitated by ICIs in the absence of immunosuppressive treatment, in contrast to the majority of reported cases. These infections are characterised by a dysregulated inflammatory immune response, and so we propose they are described as immunotherapy infections due to dysregulated immunity. This review summarises the rapidly emerging evidence of these phenomena and proposes a new framework for considering infection in the context of cancer immunotherapy.

Clinical Characteristics and Outcome for Four SARS-CoV-2-infected Cancer Patients Treated with Immune Checkpoint Inhibitors

Preliminary data suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with higher mortality among cancer patients, particularly in those on systemic therapy. It is unclear whether this applies to patients receiving immune checkpoint inhibitors (ICIs). In this case series, 74 patients from a single institution with genitourinary (GU) cancer on ICI were followed up during a 12-wk period. During this period, 11 patients (15%) developed symptoms consistent with coronavirus disease 2019 (COVID-19) and four (5%) tested positive. Two patients had metastatic urothelial cancer (treated with atezolizumab) and two had metastatic renal cancer (treated with ipilimumab and nivolumab). All had additional risk factors associated with COVID-19 mortality and two received steroids within 1 mo of infection. Two patients developed symptoms requiring hospitalisation. All four are alive 32–45 d after their first symptoms and 28–38 d after testing positive. These patients all had multiple risk factors associated with severe COVID-19. These data suggest that the higher risk of COVID-19 death associated with systemic therapy in cancer may not apply to patients on ICIs. Assessment of COVID-19 severity in these patients can be complicated by the underlying cancer and its treatment.

Do checkpoint inhibitors compromise the cancer patients' immunity and increase the vulnerability to COVID-19 infection?

The severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) has been declared a pandemic by the WHO that claimed the lives of thousands of people within a few months. Cancer patients represent a vulnerable population due to the acquired immunodeficiency associated with anti-cancer therapy. Immune checkpoint inhibitors have largely impacted the prognosis of a multitude of malignancies with significant improvement in survival outcomes and a different, tolerable toxicity profile. In this paper, we assess the safety of ICI administration in cancer patients during the coronavirus pandemic in order to guide the usage of these highly efficacious agents.

Herpes zoster granulomatous dermatitis in metastatic lung cancer treated with nivolumab: A case report

Granulomatous dermatitis (GD) is the most common among a variety of skin reactions that may occur in the varicella‐zoster virus (VZV) reactivation area. It is thought that the formation of granulomas may be the result of a delayed hypersensitivity reaction to viral envelope glycoproteins. Immune checkpoint inhibitors (ICIs), such as nivolumab stimulate T cells and promote hypersensitivity reactions, leading to the formation of granulomas in VZV wrapping proteins, thus triggering VZV‐GD. Few cases of the use of ICIs in patients diagnosed with VZV‐GD have been reported in the literature. Here, we report the clinical case of a patient with metastatic lung cancer which was treated with nivolumab who subsequently developed VZV‐GD. Accurate clinical diagnosis and prompt treatment with antiviral agents have resulted in a complete resolution of the clinical picture.

Key points

What this study adds

Few cases of ICI and VZV reactivation have been reported in the literature.

Full and timely resolution of VZV‐GD allowed the continuation of ICI treatment.