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Cheng X, Wu Z, Lin J, Wang B, Huang S, Liu M, Yang J. A two-stage ensemble learning based prediction and grading model for PD-1/PD-L1 inhibitor-related cardiac adverse events: A multicenter retrospective study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 255:108360. [PMID: 39163785 DOI: 10.1016/j.cmpb.2024.108360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/12/2024] [Accepted: 07/27/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Immune-related cardiac adverse events (ircAEs) caused by programmed cell death protein-1 (PD-1) and programmed death-ligand-1 (PD-L1) inhibitors can lead to fulminant and even fatal consequences. This study aims to develop a prediction and grading model for ircAEs, enabling graded management of patients. METHODS This study utilized medical record systems from two medical institutions to develop a prediction and grading model for ircAEs using ten machine learning algorithms and two variable screening methods. The model was developed based on a two-stage ensemble learning framework. In the first stage, the ircAEs and non-ircAEs cases were classified. In the second stage, ircAEs cases were grouped into grades 1-2 and 3-5. The experiments were evaluated using five-fold cross-validation. The model's prediction performance was assessed using accuracy, precision, recall, F1 value, Brier score, receiver operating characteristic curve area (AUC), and area under the precision-recall curve (AUPR). RESULTS 615 patients were included in the study. 147 experienced ircAEs, and 44 experienced grade 3-5 ircAEs. The soft voting classifier trained using the variables screened by feature importance ranking performed better than other classifiers in both stages. The average AUC for the first and second stages is 84.18 % and 85.13 %, respectively. In the first stage, the three most important variables are N-terminal B-type natriuretic peptide (NT-proBNP), interleukin-2 (IL-2), and C-reactive protein (CRP). In the second stage, the patient's age, NT-proBNP, and left ventricular ejection fraction (LVEF) are the three most critical variables. CONCLUSIONS The prediction and grading model of ircAEs based on two-stage ensemble learning established in this study has good performance and potential clinical application.
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Affiliation(s)
- Xitong Cheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, PR China; College of Pharmacy, Fujian Medical University, Fuzhou, PR China
| | - Zhaochun Wu
- Department of Pharmacy, Fujian Medical University Affiliated Nanping First Hospital, Nanping, PR China
| | - Jierong Lin
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, PR China; College of Pharmacy, Fujian Medical University, Fuzhou, PR China
| | - Bitao Wang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, PR China; College of Pharmacy, Fujian Medical University, Fuzhou, PR China
| | - Shunming Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, PR China; College of Pharmacy, Fujian Medical University, Fuzhou, PR China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, PR China; College of Pharmacy, Fujian Medical University, Fuzhou, PR China
| | - Jing Yang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, PR China; College of Pharmacy, Fujian Medical University, Fuzhou, PR China.
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Yu H, Wang X, Pan Y, Li H. Myasthenia gravis due to anti-PD-1 treatment for an advanced colon cancer patient: a case report and literature review. J Neurol 2024; 271:5326-5332. [PMID: 38864881 DOI: 10.1007/s00415-024-12494-y] [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: 03/11/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/13/2024]
Abstract
With the advancement of cancer treatment technologies, immunotherapy has begun to be widely utilized. Colon cancer is one of the most common types of cancer, with metastasis being a frequent occurrence in late-stage patients. Hence, immunotherapy, as an emerging and potentially effective treatment modality, merits exploration to enhance patient survival rates and clinical benefits. However, various immune-related adverse events cannot be entirely avoided. Myasthenia gravis induced by immunotherapy serves as a rare but potentially lethal adverse event, and it has been increasingly reported. Understanding the mechanisms of irAEs can aid in controlling the side effects induced by treatment. Here, we reported a case of myasthenia gravis occurring after anti-PD-1 therapy for late-stage colon cancer.
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Affiliation(s)
- Hansong Yu
- General Surgery Department, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xiaoxiao Wang
- General Surgery Department, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yuetong Pan
- General Surgery Department, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Hongyan Li
- General Surgery Department, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
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Kaira K, Mouri A, Imai H, Yamaguchi O, Kagamu H. Clinical Issue of Myasthenia Gravis Related to Immune Checkpoint Inhibitors. Curr Oncol Rep 2024:10.1007/s11912-024-01571-0. [PMID: 38954314 DOI: 10.1007/s11912-024-01571-0] [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: 06/18/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Immune-related adverse events (irAEs) are pivotal in the management of immune checkpoint inhibitors (ICIs) across various human neoplasms. While common irAEs are manageable by oncologists, the detailed features of rare complications related to ICI therapy remain elusive. Among these, immune-related myasthenia gravis (irMG) stands out as a life-threatening disease. RECENT FINDINGS Research articles published in English between 2017 and 2023 were identified using the PubMed database. Forty-six relevant research studies were examined to collate information for this review. The incidence of ICI-induced MG was found to be less than 1.0%, with approximately 20-30% of irMG patients presenting with overlap syndrome involving myocarditis and myositis. The detection of acetylcholine receptor antibodies (AChR-Ab) and elevated creatinine kinase (CK) levels proved useful in identifying 50-70% and 60-80% of cases, respectively. However, the utility of muscle-specific kinase antibodies (MuSK-Ab) in detecting irMG was limited due to a low positivity rate (0-5.3%). Ptosis emerged as the most common initial symptom of irMG, with an approximate positivity rate of 80%. Recommended treatment for irMG involves high-dose steroids in conjunction with plasmapheresis or immunoglobulins to mitigate the increased mortality associated with irMG. Early initiation of immunosuppressive therapy is imperative to prevent the worsening of irMG. Furthermore, facilitating a fulfilling social life post-hospitalization is crucial. This review sheds light on the clinical aspects and management strategies pertaining to irMG.
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Affiliation(s)
- Kyoichi Kaira
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan.
| | - Atsuto Mouri
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan
| | - Hisao Imai
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan
| | - Ou Yamaguchi
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan
| | - Hiroshi Kagamu
- Department of Respiratory Medicine, International Medical Center, Saitama Medical University, 1397-1, Yamane, Hidaka city, Saitama, 350-1298, Japan
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Wu Y, Chen D, Gao Y, Xu Q, Zhou Y, Ni Z, Na M. Immunosuppressive regulatory cells in cancer immunotherapy: restrain or modulate? Hum Cell 2024; 37:931-943. [PMID: 38814516 DOI: 10.1007/s13577-024-01083-w] [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: 04/14/2024] [Accepted: 05/22/2024] [Indexed: 05/31/2024]
Abstract
Immunosuppressive regulatory cells (IRCs) play important roles in negatively regulating immune response, and are mainly divided into myeloid-derived suppressor cells (MDSCs) and regulatory T cells (Tregs). Large numbers of preclinical and clinical studies have shown that inhibition or reduction of IRCs could effectively elevate antitumor immune responses. However, several studies also reported that excessive inhibition of IRCs function is one of the main reasons causing the side effects of cancer immunotherapy. Therefore, the reasonable regulation of IRCs is crucial for improving the safety and efficiency of cancer immunotherapy. In this review, we summarised the recent research advances in the cancer immunotherapy by regulating the proportion of IRCs, and discussed the roles of IRCs in regulating tumour immune evasion and drug resistance to immunotherapies. Furthermore, we also discussed how to balance the potential opportunities and challenges of using IRCs to improve the safety of cancer immunotherapies.
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Affiliation(s)
- Yan Wu
- Department of Burn and Plastic Surgery, The Affiliated Hospital of Jiangsu University, Zhenjiang, 210031, Jiangsu, People's Republic of China
- School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, People's Republic of China
| | - Dongfeng Chen
- School of Life Sciences, Jiangsu University, Zhenjiang, 212013, Jiangsu, People's Republic of China
| | - Yang Gao
- School of Life Sciences, Jiangsu University, Zhenjiang, 212013, Jiangsu, People's Republic of China
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, 999078, China
| | - Qinggang Xu
- School of Life Sciences, Jiangsu University, Zhenjiang, 212013, Jiangsu, People's Republic of China
| | - Yang Zhou
- School of Life Sciences, Jiangsu University, Zhenjiang, 212013, Jiangsu, People's Republic of China
| | - Zhong Ni
- School of Life Sciences, Jiangsu University, Zhenjiang, 212013, Jiangsu, People's Republic of China
| | - Manli Na
- Department of Burn and Plastic Surgery, The Affiliated Hospital of Jiangsu University, Zhenjiang, 210031, Jiangsu, People's Republic of China.
- School of Life Sciences, Jiangsu University, Zhenjiang, 212013, Jiangsu, People's Republic of China.
- International Genome Center, Jiangsu University, 301 Xuefu Road, Zhenjiang, 212013, Jiangsu, People's Republic of China.
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Niu HQ, Zheng BY, Zou MX, Zheng BW. Complex immune microenvironment of chordoma: a road map for future treatment. J Immunother Cancer 2024; 12:e009313. [PMID: 38908855 PMCID: PMC11328617 DOI: 10.1136/jitc-2024-009313] [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: 06/07/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Chordoma, a rare bone tumor, presents limited treatment options and patients typically exhibit poor survival outcomes. While immunotherapy has shown promising results in treating various tumors, research on the immune microenvironment of chordomas is still in its early stages. Therefore, understanding how the immune microenvironment of chordomas influences the outcomes of immunotherapy is crucial. METHODS We employed single-cell RNA sequencing (scRNA-seq), bulk RNA-seq, CellChat, gene set variation analysis, as well as calculation of immune features to further dissect the complex immune microenvironment of chordoma. RESULTS Previous research by van Oost et al argued that compared with other sarcomas, chordomas typically exhibit an immunologically "hot" microenvironment, a conclusion with which we concur based on their research findings. Additionally, the authors suggest that T cell-mediated immunotherapy is feasible for the majority of chordomas. However, we are inclined to categorize them as an immune-excluded phenotype according to the latest classification methods, rather than persisting with the concepts of "cold" and "hot". Unlike them, we explored immune infiltration scores (IS), T lymphocyte scoring (TLS), and human leucocyte antigen class I (HLA-I) using Bulk RNA-seq data from 126 chordoma patients and found that higher IS, TLS, and higher HLA-I expression were associated with poorer patient prognosis. Additionally, CellChat analysis of scRNA-seq results from six chordoma patients revealed no direct interaction between T cells and tumor cells. CONCLUSIONS These findings suggested that the efficacy of T cell-based immunotherapy may be limited or even ineffective for patients with chordoma.
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Affiliation(s)
- Hua-Qing Niu
- Department of Ophthalmology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Bo-Yv Zheng
- Department of Orthopedics Surgery, General Hospital of the Central Theater Command, Wuhan, China
| | - Ming-Xiang Zou
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Bo-Wen Zheng
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- Musculoskeletal Tumor Center, Peking University People's Hospital, Peking University, Beijing, China
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Gao P, Li X, He Z, Zhang H, Zhang Z, Liu Z. Lethal Immune Myocarditis and Myasthenia Gravis Due to Anti-PD-1 Treatment for a Bladder Cancer Patient: A Case Report and Possible Treatment Inspiration. Int Med Case Rep J 2024; 17:359-365. [PMID: 38651079 PMCID: PMC11034559 DOI: 10.2147/imcrj.s449525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
Immune checkpoint inhibitors (ICI) have become a new hope for many patients with advanced cancer by blocking tumor immune escape. Bladder cancer is a common malignant tumor of the urinary tract epithelium that often relapses and metastasizes after surgery, chemotherapy, and radiotherapy. Immunotherapy has dramatically improved patient survival rates and clinical benefits as a new, potentially effective therapy. However, avoidance of various immune-related adverse events (irAEs) remains an implausible idea. ICI-induced myocarditis is different from viral myocarditis, and mortality is still high with the current treatment. We report the case of an 82-year-old female patient with ICI-induced fulminant myocarditis and myasthenia gravis. Although she actively accepted the current mainstream treatment for immune-related myocarditis and myasthenia, she died of heart and respiratory failure. Analyzing and reporting the patient's disease development process and the changes in related indicators may help peers gain a deeper understanding of immune-related adverse events and reduce the mortality of immune-related myocarditis.
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Affiliation(s)
- Pan Gao
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Xinyu Li
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Ziqiu He
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Hongbo Zhang
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Zhi Zhang
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Zonglai Liu
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
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Wang C, Zhong B, He J, Liao X. Immune checkpoint inhibitor sintilimab-induced lethal myocarditis overlapping with myasthenia gravis in thymoma patient: A case report. Medicine (Baltimore) 2023; 102:e33550. [PMID: 37058040 PMCID: PMC10101245 DOI: 10.1097/md.0000000000033550] [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: 03/02/2023] [Accepted: 03/28/2023] [Indexed: 04/15/2023] Open
Abstract
RATIONALE Immune checkpoint inhibitors have been extensively used and significantly improved the clinical outcomes in multiple types of cancer. But the immune-related adverse events occur frequently, particularly in thymoma. The cardiac immune-related adverse, which is relatively rare but fatal, have been increasing reported. PATIENT CONCERNS A 45-year-old thymoma patient was admitted to our hospital after receiving anti-programmed cell death-1 treatment with sintilimab 14 days later, accompanied by abdominal pain, intermittent chest tightness and dizziness. DIAGNOSES The laboratory tests revealed elevated serum troponin I. Electrocardiogram reported the prolongation of QTc interval. Echocardiography showed small amount of pericardial effusion, a left ventricular ejection fraction of 71%. Coronary artery computed tomography angiography revealed localized noncalcified plaque in the middle of the left anterior descending artery and mild stenosis of the lumen. Enhanced computed tomography scanning of the whole abdomen showed no abnormal signs in the parenchyma organs. Combining the results of the examinations, the Immune checkpoint inhibitor induced myocarditis was diagnosed. INTERVENTIONS The patient was treated with glucocorticoids (120 mg/day, IV, methylprednisolone) within 24 hours of admission. Seven days later, the patient experienced tachy ventricular arrhythmia and cardiogenic shock and was transferred to intensive care unit after electrical cardioversion, tracheal intubation and cardiopulmonary resuscitation. Intravenous immunoglobulin therapy at 25 g/day was given and methylprednisolone was reduced to 40 mg/day for the next 3 days. Intravenous esmolol and lidocaine were used for correcting arrhythmias. Ventilator positive pressure ventilation was used for respiratory support. She was administrated with plasmapheresis when the electrocardiogram monitoring showed ventricular arrhythmia storms. OUTCOME The patient progressed to ventricular arrhythmia storms and cardiac failure, which eventually resulted in death. LESSONS The case aims to raise awareness of immune-mediated cardiotoxicity and bring thoughts to the prospects of immunotherapy in thymoma.
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Affiliation(s)
- Chen Wang
- Department of Oncology, Ganzhou People’s Hospital, Ganzhou, Jiangxi Province, China
| | - Bingdi Zhong
- Department of Oncology, Ganzhou People’s Hospital, Ganzhou, Jiangxi Province, China
| | - Jing He
- Department of Oncology, Ganzhou People’s Hospital, Ganzhou, Jiangxi Province, China
| | - Xiaohong Liao
- Department of Oncology, Ganzhou People’s Hospital, Ganzhou, Jiangxi Province, China
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Seligman C, Chang YM, Luo J, Garden OA. Exploring the role of immune checkpoint inhibitors in the etiology of myasthenia gravis and Lambert-Eaton myasthenic syndrome: A systematic review. Front Neurol 2023; 13:1004810. [PMID: 36698907 PMCID: PMC9868566 DOI: 10.3389/fneur.2022.1004810] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Background While immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of cancer, their administration has been associated with a variety of immune-related adverse events (irAEs), including myasthenia gravis (MG), and Lambert-Eaton myasthenic syndrome (LEMS). Objective To provide a comprehensive synthesis of the evidence supporting an etiological role for ICIs in MG and LEMS in patients with no prior history of autoimmune disease. Hypothesis ICIs may trigger MG and LEMS in patients with no prior susceptibility to autoimmune disease. Methods Relevant primary research on Medline was interrogated using a series of search algorithms. Search terms were constructed based on the PICOS tool endorsed by the Cochrane Collaboration, which describes population, intervention, comparison, outcomes, and study design. Papers were screened according to inclusion and exclusion criteria. Additional papers were retrieved from the reference lists of screened papers. Each paper included in the qualitative synthesis was assigned an integrated metric of evidence (IME) value, ranging from 0 to 7, based on study design, quality of data, likelihood of a causal link between the immune checkpoint inhibitor(s) and MG/LEMS, confidence of MG/LEMS diagnosis, and the number of patients treated with an ICI prior to MG/LEMS diagnosis. Results Ninety-four papers describing at least one patient treated with ICI(s) prior to the onset of MG and/or LEMS were documented. Overall evidence for a causal link between ICI administration and MG/LEMS was low, with a median IME value of 2.88 (range 2.05-6.61). Conclusions There is a paucity of evidence in support of an etiological relationship between ICIs and MG/LEMS, due largely to the lack of mechanistic studies and/or prospective clinical trials with relevant study endpoints. The current literature is dominated by case reports and retrospective cohort studies, which inherently yield only low-level evidence, supporting the need for further work in this area. A role of ICIs in the etiology of MG/LEMS remains plausible, arguing for continued vigilance for irAEs in patients treated with these drugs. We argue that there is a need for future mechanistic, high quality, large-scale studies specifically investigating the possible etiological role of ICIs in MG/LEMS.
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Affiliation(s)
- Carly Seligman
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Yu-Mei Chang
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, United Kingdom
| | - Jie Luo
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Oliver A. Garden
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States,Dean's Office, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States,*Correspondence: Oliver A. Garden ✉
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Xu A, Yuan M, Zhan X, Zhao G, Mu G, Wang T, Hu H, Fu H. Early detection of immune checkpoint inhibitor-related subclinical cardiotoxicity: A pilot study by using speckle tracking imaging and three-dimensional echocardiography. Front Cardiovasc Med 2022; 9:1087287. [PMID: 36620612 PMCID: PMC9812579 DOI: 10.3389/fcvm.2022.1087287] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
Background Early detection of subclinical cardiotoxicity of immune checkpoint inhibitor (ICI) therapy can be challenging. Objective To evaluate subclinical cardiac dysfunction using two-dimensional speckle tracking imaging (2D-STI) and three-dimensional echocardiography in Chinese patients. Methods Fifty-five consecutive patients with malignant tumors treated by immunotherapy were included. They were examined by echocardiography before immunotherapy and after immunotherapy. Left ventricular ejection fraction (LVEF) was calculated in three-dimensional imaging. Moreover, left ventricular global longitudinal peak systolic strain (LVGLS), left ventricular global circumferential peak systolic strain (LVGCS), right ventricular global longitudinal systolic strain (RVGLS), right ventricular free wall longitudinal peak systolic strain (RVFWLS), and tricuspid annular plane systolic excursion (TAPSE) were evaluated. Clinical and laboratory parameters were recorded. Cardiac toxicity events were defined as the presence of heart failure symptoms, LVEF reduction, and increase in troponin. Subclinical cardiac toxicity was defined as cardiac dysfunction associated with ICI treatment, with absent or delayed ICI-associated cardiotoxicity clinical symptoms. Results Compared with baseline, the LVGLS, TAPSE, and RVGLS significantly deteriorated after ICI treatment [(-18.63 ± 2.53)% vs. (-17.35 ± 2.58)%, P = 0.000; 18.29 ± 6.23 vs. 14.57 ± 3.81, P = 0.0001; and (-18.45 ± 4.65)% vs. (-14.98 ± 3.85)%, P = 0.0001, respectively]. LVGLS (-17.35 ± 2.58, P = 0.000), TAPSE (14.57 ± 3.81, P = 0.0001), and RVGLS [(-14.98 ± 3.85)%, P = 0.0001] were decreased after ICI immunotherapy. Kaplan-Meier curve analysis showed that LVGLS was more sensitive than the cardiac toxicity events to assess ICI-related subclinical cardiac dysfunction (log-rank P = 0.205). The ROC curve showed that the cutoff value of ΔLVGLS was -13%. Conclusion Subclinical cardiac dysfunction can be detected using two-dimensional speckle-tracking imaging. LVGLS, RVGLS, and TAPSE are more sensitive indices for detection. Clinical trial registration [https://www.chictr.org.cn/showprojen.aspx?proj=27498], identifier [ChiCTR1800016216].
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Affiliation(s)
- Aiqing Xu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China,Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ming Yuan
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xiaoping Zhan
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gangjian Zhao
- Department of Urology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Guanyu Mu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Tingting Wang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Hailong Hu
- Department of Urology, Second Hospital of Tianjin Medical University, Tianjin, China,*Correspondence: Hailong Hu,
| | - Huaying Fu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China,Huaying Fu,
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Chen R, Zhou M, Zhu F. Immune Checkpoint Inhibitors Related to Cardiotoxicity. J Cardiovasc Dev Dis 2022; 9:jcdd9110378. [PMID: 36354777 PMCID: PMC9697232 DOI: 10.3390/jcdd9110378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have now emerged as a mainstay of treatment for various cancers. Along with development of ICIs, immune-related adverse effects (irAEs) have aroused wide attention. The cardiac irAE, one of the rare but potentially fatal effects, have been reported recently. However, the clinical comprehension of cardiac irAEs remains limited and guidelines are inadequate for cardio-oncologists to tackle the problem. In this review, we have summarized current classifications of, manifestations of, potential mechanisms of, and treatment for ICI-related myocardial injury in order to provide some clues for the understanding of cardiac irAEs in clinical work.
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Affiliation(s)
- Ru Chen
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Clinic Center of Human Gene Research, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Min Zhou
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Key Laboratory of Respiratory Diseases, National Ministry of Health of the People’s Republic of China and National Clinical Research Center for Respiratory Disease, Wuhan 430022, China
- Correspondence: (M.Z.); (F.Z.)
| | - Feng Zhu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Clinic Center of Human Gene Research, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: (M.Z.); (F.Z.)
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Yousif LI, Tanja AA, de Boer RA, Teske AJ, Meijers WC. The role of immune checkpoints in cardiovascular disease. Front Pharmacol 2022; 13:989431. [PMID: 36263134 PMCID: PMC9574006 DOI: 10.3389/fphar.2022.989431] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) are monoclonal antibodies which bind to immune checkpoints (IC) and their ligands to prevent inhibition of T-cell activation by tumor cells. Currently, multiple ICI are approved targeting Cytotoxic T-lymphocyte antigen 4 (CTLA-4), Programmed Death Protein 1 (PD-1) and its ligand PD-L1, and Lymphocyte-activation gene 3 (LAG-3). This therapy has provided potent anti-tumor effects and improved prognosis for many cancer patients. However, due to systemic effects, patients can develop immune related adverse events (irAE), including possible life threatening cardiovascular irAE, like atherosclerosis, myocarditis and cardiomyopathy. Inhibition of vascular IC is associated with increased atherosclerotic burden and plaque instability. IC protect against atherosclerosis by inhibiting T-cell activity and cytokine production, promoting regulatory T-cell differentiation and inducing T-cell exhaustion. In addition, PD-L1 on endothelial cells might promote plaque stability by reducing apoptosis and increasing expression of tight junction molecules. In the heart, IC downregulate the immune response to protect against cardiac injury by reducing T-cell activity and migration. Here, inhibition of IC could induce life-threatening T-cell-mediated-myocarditis. One proposed purpose behind lymphocyte infiltration is reaction to cardiac antigens, caused by decreased self-tolerance, and thereby increased autoimmunity because of IC inhibition. In addition, there are several reports of ICI-mediated cardiomyopathy with immunoglobulin G expression on cardiomyocytes, indicating an autoimmune response. IC are mostly known due to their cardiotoxicity. However, t his review compiles current knowledge on mechanisms behind IC function in cardiovascular disease with the aim of providing an overview of possible therapeutic targets in prevention or treatment of cardiovascular irAEs.
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Affiliation(s)
- Laura I. Yousif
- Department of Experimental Cardiology, University Medical Center Groningen, Groningen, Netherlands
| | - Anniek A. Tanja
- Graduate School of Life Science, Utrecht University, Utrecht, Netherlands
| | - Rudolf A. de Boer
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Arco J. Teske
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wouter C. Meijers
- Department of Experimental Cardiology, University Medical Center Groningen, Groningen, Netherlands
- *Correspondence: Wouter C. Meijers,
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Ji H, Wen Z, Liu B, Chen H, Lin Q, Chen Z. Sintilimab induced ICIAM in the treatment of advanced HCC: A case report and analysis of research progress. Front Immunol 2022; 13:995121. [PMID: 36091070 PMCID: PMC9458972 DOI: 10.3389/fimmu.2022.995121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 01/23/2023] Open
Abstract
Immune checkpoint inhibitor-associated adverse reactions (irAEs) are a clinical treatment issue that requires additional attention when ICIs have significant survival benefits in patients with advanced hepatocellular carcinoma (HCC). Among them, ICIs-associated myocarditis (ICIAM) is a kind of severe irAE with a high mortality rate (17%–50%). Despite its low incidence (PD1/PD-L1 related: 0.41%–0.8%), ICIAM can significantly disturb the decision making of therapeutic schemes and even the survival outcomes of patients. ICIAM induced by sintilimab has not been reported in any complete clinical studies yet and understanding the clinical characteristics involved may inform better practices for the management. Here, we reported a 78 y/o patient with advanced HCC, who experienced ICIAM induced by sintilimab within a short course from treatment onset and found that adequate baseline examination before the implementation of the therapeutic scheme, regular monitoring of myocardial enzymonram and cardiac imaging were measures for the early detection, while glucocorticoid pulse therapy is still the best choice with timely and sufficient application. Simultaneously, the combination of other immunosuppressants may lead to better results. New-predictive markers and examination methods are still required to facilitate the early detection.
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13
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Lei Y, Zheng X, Huang Q, Li X, Qiu M, Liu M. Intrinsic Differences in Immune Checkpoint Inhibitor-Induced Myocarditis: A Retrospective Analysis of Real World Data. Front Pharmacol 2022; 13:914928. [PMID: 35865949 PMCID: PMC9294234 DOI: 10.3389/fphar.2022.914928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/06/2022] [Indexed: 12/01/2022] Open
Abstract
Immune-related myocarditis is a severe and even life-threatening immune-related adverse event (irAE) which may also be underestimated due to the challenge in diagnosis. The inherent difference between individuals with immune-associated myocarditis has received little attention. Our study aimed to identify which baseline characteristics could contribute to distinguishing mild from severe ICI myocarditis. A retrospective analysis was conducted between March 2019 and June 2020 in West China Hospital, and 18 patients with immune-related myocarditis were studied. Patients were classified as having mild (n = 12) or severe myocarditis (n = 6), according to the clinical manifestations and hemodynamic complications. Factors associated with severe myocarditis were identified by comparing covariates derived from medical records in various groups. In this retrospective analysis, the median age of the 18 patients was 60 years old. Most myocarditis cases occur early and approximately after the first or second ICI infusion. The severity of myocarditis may be correlated with lactate dehydrogenase (LDH) (p = 0.04) and troponin levels (p = 0.0057). The relationship between troponin and myocarditis was further confirmed in another cohort, which included 30 patients. In addition, patients are more likely to develop multi-irAEs, and myositis was the most common second irAE. Those who experience multi-irAEs usually had significantly higher LDH (p = 0.02) and myoglobin levels (p = 0.02) than those who did not experience them. All patients were treated with steroids timely, and the mortality rate was 5.6% in our study. In this study, we explored risk factors for severe myocarditis and emphasized the importance of a multidisciplinary team in assisting diagnosis and treatment options. It is critical to initiate corticosteroid therapy, regardless of the severity of the myocarditis.
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Xia C, Huang W, Chen YL, Fu HB, Tang M, Zhang TL, Li J, Lv GH, Yan YG, Ouyang ZH, Yao N, Wang C, Zou MX. Coexpression of HHLA2 and PD-L1 on Tumor Cells Independently Predicts the Survival of Spinal Chordoma Patients. Front Immunol 2022; 12:797407. [PMID: 35145510 PMCID: PMC8824251 DOI: 10.3389/fimmu.2021.797407] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/31/2021] [Indexed: 12/19/2022] Open
Abstract
Background Immunotherapy only achieves efficacy in some cancer patients, and less is known about other immune checkpoint molecules in chordoma. Here, we aimed to determine the expression of PD-L1, HHLA2, B7H3, IDO-1 and Galectin-9 in spinal chordoma and evaluated their association with tumor infiltrating lymphocytes (TILs), clinicopathological characteristics and survival of patients. Methods Using multiplexed quantitative immunofluorescence (QIF), we simultaneously measured the levels of five different immune checkpoint molecules and major TIL subsets in 92 human spinal chordoma samples. Results Tumor HHLA2 and PD-L1 were positive in 80.0% and 86.0% of cases, respectively. However, B7H3, IDO-1 and Galectin-9 positivity on tumor cells were only seen in 21.0% of cases, despite all showing predominantly stromal expression. Coexpression of these QIF markers in the tumor compartment was scarcely detected except for PD-L1 and HHLA2, which was observed in 69.6% of cases. While tumoral HHLA2 and stromal B7H3 expressions were associated with an aggressive tumor phenotype, suppressive immune response (specifically including elevated PD-1+ TILs level and decreased CD8+ TIL density) and poor prognosis, stromal levels of PD-L1 and Galectin-9 predicted the opposite outcomes. Importantly, HHLA2 and PD-L1 coexpression on tumor cells independently predicted both worse local recurrence-free survival and overall survival. Conclusion These data provide a better understanding of the immunosuppressive mechanism in chordoma and may be useful for the development of combination or novel immunotherapy approaches aiming to improve therapeutic efficacy and survival.
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Affiliation(s)
- Chao Xia
- The First Affiliated Hospital, Health Management Center, Hengyang Medical School, University of South China, Hengyang, China.,Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Wei Huang
- The First Affiliated Hospital, Health Management Center, Hengyang Medical School, University of South China, Hengyang, China
| | - Yun-Liang Chen
- Shenzhen Audaque Data Technology Co., Ltd., Shenzhen, China
| | - Hai-Bin Fu
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Ming Tang
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Tao-Lan Zhang
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Jing Li
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Guo-Hua Lv
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi-Guo Yan
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Zhi-Hua Ouyang
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Nvzhao Yao
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Cheng Wang
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Ming-Xiang Zou
- Department of Spine Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
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Pathak R, Katel A, Massarelli E, Villaflor VM, Sun V, Salgia R. Immune Checkpoint Inhibitor-Induced Myocarditis with Myositis/Myasthenia Gravis Overlap Syndrome: A Systematic Review of Cases. Oncologist 2021; 26:1052-1061. [PMID: 34378270 DOI: 10.1002/onco.13931] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/30/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The development of immune checkpoint inhibitors (ICIs) represents a paradigm shift in the treatment of cancers. Despite showing remarkable efficacy, these agents can be associated with life-threatening immune-related adverse events. In recent years, several cases of myocarditis with myositis and/or myasthenia gravis overlap syndrome (IM3OS) have been reported. However, given the rarity, the clinical features and outcomes of these cases remain poorly understood. We, therefore, attempted to systematically review and summarize all cases of IM3OS reported in the literature. MATERIALS AND METHODS Studies reporting IM3OS were identified in Embase and MEDLINE. Only case reports and case series published in journals or presented at conferences were included. We conducted a systematic review according to the PRISMA Harms guidelines. RESULTS A total of 60 cases were eligible. The patients' median age was 71 years, and the majority (67%) were males; melanoma was the most common indication for ICIs (38%). The most-reported symptoms were fatigue (80%) and muscle weakness (78%). The median number of doses to the development of IM3OS was one. The average creatine kinase level was 9,645 IU/L. Cardiac arrhythmias occurred in 67% of patients, and 18% had depressed ejection fraction. Initial treatment consisted of immunosuppression with high-dose steroids and supportive therapies. Sixty percent of the patients died in hospital because of acute complications. CONCLUSION IM3OS can be associated with significant mortality and morbidity. Prospective studies are needed to understand the optimal approach to diagnose and manage these patients and to develop biomarkers to predict the occurrence and severity of this rare but serious condition. IMPLICATIONS FOR PRACTICE Clinicians should suspect coexisting myositis and/or myasthenia gravis in all patients with immune checkpoint inhibitor-induced myocarditis, given their propensity to occur together. Early recognition and prompt treatment with the help of a multidisciplinary team might help improve the outcomes of this life-threatening condition.
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Affiliation(s)
- Ranjan Pathak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Anjan Katel
- Department of Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Erminia Massarelli
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Victoria M Villaflor
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Virginia Sun
- Department of Population Science, City of Hope, Duarte, California, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
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